Integrated Adult Services (IAS) Pilot Project Application Description of the IAS Project The Manitoba government is collaborating with persons with disabilities, the Manitoba Human Rights Commission and the Winnipeg Regional Health Authority (WRHA) to develop and pilot the Integrated Adult Services (IAS) project designed to assess and address gaps in services for adults 18 years of age or older with: 1. a medical diagnosis and permanent complex physical disability-related needs; or 2. a medical diagnosis and permanent complex physical and intellectual disability related needs. The IAS pilot project is seeking individuals in the Winnipeg Health Region who are currently experiencing challenges accessing supports and services in Manitoba and may have but are not limited to complex needs in the area(s) of: Personal Care, Home Care, Housing, Day Services, Employment, Equipment, Mental Health, Prescription Medication, Transportation, Income and Respite. The IAS Steering Committee reserves the right to exercise discretion during the selection process should an applicant not meet the criteria outlined in items 1 or 2, but is clearly experiencing significant disability-related barriers to obtaining supports and services in the areas mentioned above. Participants will take part in an innovative process designed to identify service barriers or gaps and work towards creative solutions that enhance quality of life and a person centred evaluation designed to measure participant outcomes. It is anticipated that the duration of the pilot program will be for up to 30 months. The IAS project is inviting individuals interested in participating in the pilot to apply through one of the following methods: * Completing an online e-form at: gov.mb.ca/fs/ias/index.html * Completing the text or Word version of the application form and sending to the Department of Families/WRHA by email IntegratedAdultServices@gov.mb.ca or by mailing or dropping off in person to 3-170 Goulet Street, Winnipeg (attention Integrated Adult Services Pilot); or sending by fax to (204) 948-3282 * Providing information in the body of an email and sending to IntegratedAdultServices@gov.mb.ca; or * Calling (204) 945-6533 to provide information verbally or to request another application format. The deadline for IAS applications is December 9, 2022 at 11:59 p.m. C.S.T Integrated Adult Services Pilot Project Application Form Applicant given name(s): Applicant surname: Name of person completing form (if other than applicant) and relationship to applicant: Applicant address: Applicant's medical diagnosis (es): Applicant is at least 18 years of age: Yes__ No__ Applicant has a complex disability: Yes__ No__ Unsure__ Please check all areas in which the applicant is seeking support: __ Personal Care __ Mental Health __ Home Care __ Prescription Medication __ Housing __ Transportation __ Day Services __ Income __ Employment __ Respite __ Equipment __ Other ________________ Please describe the impact the applicant's disability has on their daily living: Contact information: Telephone: Email: Preferred method for follow-up communication: __ Telephone __ Email __ Other (please specify): _________________________________________________ Demographic Information: 1. How old are you? __ 18-24 __ 55-64 __ 25-34 __ 65-74 __ 35-44 __ 75+ __ 45-54 __ Prefer not to respond 2. How do you identify? (Select all that apply) __ Woman __ Transgender __ Man __ Two-spirit __ Non-binary __ Another gender identity __ Prefer not to respond 3. Do you identify as Indigenous? If yes, please specify which you identify with. (Select all that apply) __ First Nation __ Unknown __ Inuit __ Prefer not to disclose __ M�tis 4. We recognize this list of racial or ethnic identifiers may not exactly match how you would describe yourself. Keeping that in mind, which of the following best describes the racial or ethnic community that you belong to? __ African __ Southeast Asian __ Black __ Latin American __ Chinese __ North American Indigenous __ Filipino __ White __ South Asian __ Prefer not to respond __ Other _______________ 5. In what community do you reside? __ Winnipeg __ West St. Paul __ East St. Paul __ Churchill Authorization to collect information The Manitoba government and the Winnipeg Regional Health Authority are authorized to collect your personal information and personal health information under clause 36(1)(b) of The Freedom of Information and Protection of Privacy Act ("FIPPA") and section 13(1) of The Personal Health Information Act ("PHIA") respectively, as the information is directly related to and necessary for determining eligibility for the IAS pilot project. Your information is protected by the privacy provisions under FIPPA and PHIA. The Manitoba government and Winnipeg Regional Health Authority cannot use or disclose your personal or personal health information for any other purpose, unless you consent or the administrators of the IAS pilot project are authorized or required to do so under FIPPA or PHIA. Consent I/we hereby authorize the release of the information in this application to representatives of the Manitoba government and Winnipeg Regional Health Authority for the purpose of determining eligibility for the Integrated Adult Services pilot project. I/we understand that submitting an application form does not guarantee the applicant's participation in the IAS pilot project and that additional information may be requested at a later date for the purpose of assessing eligibility. If you have questions about the collection of information, please contact Krystina Costello, case manager, Department of Families, 3-170 Goulet St, Winnipeg, (204) 945-6533 Applicant signature (or signature of applicant's legal representative): Nature of legal authority (if applicable): Date: APPLICATION AVAILABLE IN OTHER FORMATS UPON REQUEST. PLEASE CALL 204-945-6533 FOR ASSISTANCE.