New Admissions & Resident Services

Home County Services Dufferin Oaks Long Term Care Home New Admissions & Resident Services

For those who have gone through the application process and are moving into Dufferin Oaks…..Welcome! We are very honoured that you have selected our home as your new home. We have prepared a few documents to help make your transition go as smoothly as possible.

24-hour nursing and personal support care
Nutritional services (includes all meals, snacks, on-site Registered Dietitian)
Laundry
Accommodation, i.e. furnished room, cleaned and maintained
Medical Services
Physiotherapy, Occupational Therapy
Pharmacy Services
Lab Services
Imaging
Therapeutic programming
Spiritual programming
Social Worker

Family Information Assessment

Applicant/family must complete prior to admission meeting.

Applicant Information

Admission Date (mm/dd/yyyy)(Required)

Name(Required)

First Middle Last

Preferred Name(Required)

First

Gender(Required)

Marital Status(Required)

Social Insurance Number (SIN)(Required)

Health Card Number(Required)

Health Card Number Version Code(Required)

Date of Birth (mm/dd/yyy)(Required)

Is the applicant a veteran?(Required)

Yes

Veteran's Number

Is the applicant's spouse a veteran?(Required)

Yes

Spouse's Verteran's Number

Is the applicant indigenous?(Required)

Yes

If the applicant is indigenous, please list the band or treaty.

Demographic Information

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Last place of residence prior to admission

Did the applicant live alone prior to admission?(Required)

Yes

Type of residence immediately prior to admission(Required)

If the residence prior to admission was not a private home, what was the name?

Residential History

Check all that apply for the five years prior to admission.(Required)

Prior stay at this facility

Prior stay at another similar level of care

Prior stay in other board or care facility (retirement home)

Prior stay in a psychiatric facility

Prior stay in a development disability facility

None of the above

Education

Choose the highest level of education completed.(Required)

No schooling

Grade 8 or less

Grade 9 to Grade 11

High School Graduate

Technical or Trade School

Some College

Bachelor’s Degree

Master’s Degree or higher

Unknown

Power of Attorney Finance

If you have not established Powers of Attorney or a Will, we recommend you seek legal advice in order to do so.

Is there a Power of Attorney for finances?(Required)

Yes

Please provide information on who the Power of Attorney for Finances is. If joint, please provide information on both parties.

1. Name

First Last

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number

Alternate Phone Number

Email Address

2. Name (Joint With)

First Last

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number

Alternate Phone Number

Email Address

Power of Attorney Personal Care

Is there a Power of Attorney for personal care?(Required)

Yes

Please provide information on who the Power of Attorney for personal care is. If joint, please provide information on both parties.

1. Name

First Last

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number

Alternate Phone Number

Email Address

2. Name (Joint With)

First Last

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number

Alternate Phone Number

Email Address

Does the applicant manage their own affairs?(Required)

Yes

Other Important Contacts (If Applicable)

1. Name

First Last

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Alternate Phone Number

2. Name

First Last

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Alternate Phone Number

Will Information

Is there an Advance Directive or Living Will in place?(Required)

Yes

Is there a Will prepared?(Required)

Yes

If so, where was it filed and who is (are) the executor(s)?

Does the applicant have a prearranged funeral?(Required)

First Choice

Second Choice

Third Choice

If yes, please note the location and cemetery.

Daily Routine

Daily Events

Stays up late at night(Required)

Naps regularly during the day(Required)

Goes out 1+ days a week(Required)

Stays busy with hobbies, reading or fixed daily routine(Required)

Moves independently indoors (with mobility aids as needed)(Required)

Uses tobacco products daily(Required)

Eating

Distinct food preferences(Required)

If yes, please specify.

Distinct food dislikes(Required)

If yes, please specify.

Food allergies(Required)

If yes, please specify.

Eats between meals most days(Required)

Use of alcoholic beverages(Required)

Drinks per week

ADL Patterns

In bedclothes most of the day(Required)

Wakens to toilet all or most nights(Required)

Has regular bowel movement patterns(Required)

Social

Daily contact with relatives or close friends(Required)

Usually attend church/temple/synagogue(Required)

Finds strength in faith(Required)

Daily animal companion or presence(Required)

Involved in group activities(Required)

Getting To Know Our New Resident

In order to enhance our strategies for quality care, please share as much as possible.

Nicknames

Briefly describe previous lifestyle

Sources of hope/comfort/joy/inspiration/favourite things?

Interests and hobbies?

Life role/previous occupations

They are most proud to be known as?

Pets? Describe and list names. Any animal fears or dislikes?

Significant persons in life & their relationship.

Are there any stresses or conflicts we should be aware of?

Significant high points in life.

Significant low points in life/trauma.

Travel (place, events, with who?). Places they’ve lived?

Is there an affiliation with a particular religion or church? If so, please specify denomination (example: Anglican, Roman Catholic, United, etc.)

Other preferences (meal time/socialization/sleep/wake):

Do they enjoy music? If so, please describe favourite instruments, artists, genres, etc.

Cultural affiliations and associated practices

Other pertinent information?

If the new resident is anxious, has dementia, or you are anticipating a difficult transition, please provide the following additional information.

Do you have any concerns that your family member will attempt to leave the home unattended/unaccompanied?(Required)

Things that comfort resident when they are having a bad day

When they feel restless they might need

When they feel angry or agitated they might need

When they repeat themselves they may need

When they hide or hoard things they might need

When they pace they might need

When helping with their care please make the process easier by:

Form Completed By:(Required)

First Last

Date Completed (mm/dd/yyy)(Required)

Information Collection

The personal information on this form is collected under the authority of the Fixing Long-Term Care Act and will be used for the purposes of providing care to the resident. Questions about this collection should be directed to Associated Administrator, Dufferin Oaks Long Term Care Home, 151 Centre Street, Shelburne, ON L9V 3R7 or 519-925-2140 ext. 5239.

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New Admissions & Resident Resources

Family Information Assessment

Applicant Information

Demographic Information

Residential History

Education

Power of Attorney Finance

Power of Attorney Personal Care

Other Important Contacts (If Applicable)

Will Information

Daily Routine

Daily Events

Eating

ADL Patterns

Social

Getting To Know Our New Resident

Information Collection