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APPLICATION FORM CONSUMPTION AND TREATMENT SERVICE (CTS) PROGRAM

Before completing this application form, please review the Consumption and Treatment Services (CTS) Application Guide which outlines the CTS program requirements and the application process. This application form must be fully completed and submitted to the Ministry of Health and Long-Term Care in order to be considered for funding.

Please include your completed Health Canada Supervised Consumption Service (SCS) application, or verification you have a Health Canada exemption, along with this application form.

APPLICANT INFORMATION Name of the applicant organization:

Brief description of the applicant organization, include:

Mandate/mission

Governance structure, including list of Board of Directors

List of services currently provided to people who use drugs, including existing harm reduction services

APPLICANT CONTACT INFORMATION Name:

Name: Name:

Title:

Title: Title:

Organization:

Organization: Organization:

Phone:

Phone: Phone:

Email:

Email: Email:

Address:

Address: Address:

Responsible Person in Charge (RPIC) designated under the federal exemption:

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OVERVIEW OF CONSUMPTION AND TREATMENT SERVICES

1. LOCAL CONDITIONS

CONTEXT Local or neighborhood evidence to support the site selection for the proposed CTS:

Examples may include monitoring and reporting data from existing response efforts and harm reduction services

Include any relevant documents as attachments

Please describe how the proposed model is best suited to local conditions (Maximum 500 words):

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2. CAPACITY TO PROVIDE CONSUMPTION AND TREATMENT SERVICES

Name of Site:

Full Site Address (Include postal code):

Does the applicant own the land or property on which CTS services will be offered? Yes. No. If ‘No’, a letter of permission from the land/property owner to operate CTS on site should be included with the application.

MANDATORY ONSITE HARM REDUCTION SERVICES Describe how your proposed service will deliver each mandatory services and indicate how they will be delivered (e.g. who will deliver each service, how many clients can each service accommodate at one time, how will clients access each service, client flow). (Maximum 200 words each)

Supervised consumption and overdose prevention services:

Injection, intranasal, oral1

Harm reduction services:

Education (on harm reduction, safe drug use practices, safe disposal of equipment)

1The provincial CTS program does not currently cover inhalation. All other forms of consumption offered on site will be required to align with the organization’s federal exemption.

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Harm reduction services:

First aid/wound care

Harm reduction services:

Distribution and disposal of harm reduction supplies

Harm reduction services:

Provision of take-home naloxone

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Removal of inappropriately discarded harm reduction supplies:

Includes pick-up of inappropriately discarded supplies surrounding the CTS area using appropriate equipment

Public education:

Description

Other harm reduction services and supports (if applicable):

Description

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MANDATORY WRAP-AROUND SERVICES2

Note that Section 2.1 of the Consumption and Treatment Services Application Guide requires a CTS to have onsite or defined pathways to:

Addictions treatment services

Mental health services

Primary care services

Social services (e.g. housing, food, employment, other)For each service listed please indicate below (via drop down menu) if it is available onsite or through a defined pathway. Please also describe your organization’s capacity to provide either onsite access or a defined pathway to each service. For services delivered through a defined pathway, under the applicable sections below please list:

Name of the organization that provides the service(s)

Proximity of service (in metres) to CTS

How service will be delivered

Rationale for why this service/provider is being chosen

Estimated wait time to access services

Any supports the CTS will provide in linking clients to the offsite services.For services delivered onsite, under the applicable sections below please list:

Estimated wait time to access services

ONSITE OR DEFINED PATHWAYS TO SERVICES:

Addictions treatment

Opioid agonist treatment (e.g. methadone, suboxone)

Other (e.g. detox, residential or community treatment)

Choose an item:

Describe (Maximum 250 words):

2 CTS funding does not cover the direct costs of wrap-around services. Successful applicants should be able to leverage budgeted/existing onsite services, as well as partnerships for referrals.

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Mental health services

Choose an item:

Describe (Maximum 250 words):

Primary care services Choose an item:

Describe (Maximum 250 words):

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Social services (e.g. counselling, housing, food, employment)

Choose an item:

Describe (Maximum 250 words):

Other (if applicable; e.g. social assistance)

Choose an item:

Describe (Maximum 250 words):

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SERVICE DELIVERY MODEL Days of the week and hours of CTS operation:

Please describe how the hours of operation are best suited to the local conditions and/or how people who use drugs were engaged to inform suitable hours (Maximum 150 words):

Please describe the hours of any services that differ from CTS operational days and hours (if any), and the rationale for those differences (Maximum 150 words):

Proposed number of consumption booths or spaces:

Estimated number of clients per day3:

Please describe the staffing model and how the minimum staffing requirement will be met (Maximum 200 words): 4 Designated health professional(s) present at all times

Peers/persons with lived experienceInclude:

Please identify the staff position titles, the associated number of FTEs, and a rationale for that staff position o Include the designation of the health professional(s), and the duties they will perform

How staff will provide immediate overdose response

How staff will prevent and manage security incidents

How staff will deliver services onsite and facilitate access to mandatory services that are offsite

3 Can be based on current number of clients (who consume drugs) served per day. 4 CTS funding must not be used for physician funding to deliver clinical services.

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Additional comments on the model of service (Maximum 200 words):

SITE REQUIREMENTS Brief description of site (Maximum 200 words):

Describe how the space is being leveraged to offer CTS services5

Briefly indicate the size of the site (square footage and how many clients and staff can the site accommodate at a time)

Include a basic floorplan, with measurements, with the application that indicates where the following will be located:

o Service intake, consumption, and post-consumption services(i.e. aftercare room)o Onsite serviceso Separate washrooms for staff use and client useo Foot wash station

5 Please refer to Section 2.3 of the CTS Application Guide

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PHYSICAL SAFETY AND SECURITY

Does the site meet ministry design standards for a consumption service? 6 Yes No

Does the site meet provincial and municipal safety requirements? (e.g., building codes) Yes No

Is a fire safety plan in place? If yes, please attach a copy. Yes No

Is a security plan in place? 7 If yes, please attach a copy. Yes No Please make sure the security plan includes mechanisms to:

Control CTS site access (and evacuation if necessary)

Discourage loitering outside the CTS

Ensure staff are trained on instances in which law enforcement should be contacted

Ensure staff are trained on Infection Prevention and Control (IPAC) proceduresComply with Health Canada rules related to possession, production, trafficking/sharing, and administering ofsubstances

Do EMS, first responders, and fire service have access to and within the site? Yes No

Does the site meet occupational health and safety requirements? Yes No

Does the site meet infection prevention and control requirements Yes No

3. PROXIMITY

Is another CTS, or similar service, in the same municipality? Yes No

If yes, how far is the proposed CTS from any existing CTS or similar service? Distance in metres or KM

How far is the closest licensed child care centre from the proposed CTS? Distance in metres or KM

If within 100m-200m, please describe how community concerns will be addressed through community consultation, and through ongoing community engagement. (Maximum 50 words) Please include letters of support from the child care centre(s), if available.

How far is the closest park from the proposed CTS? Are there other parks nearby? Please list them and the distance from the CTS:

Distance in metres or KM

6 Please refer to Appendix A of the CTS Application Guide for CTS design standards 7 Please refer to Section 2.3 of the CTS Application Guide

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If within 100m-200m, please describe how community concerns will be addressed through community consultation, and through ongoing community engagement. (Maximum 50 words)

How far is the closest school, including post-secondary institutions, from the proposed CTS?

Distance in metres or KM

If within 100m-200m, please describe how community concerns will be addressed through community consultation, and through ongoing community engagement. (Maximum 50 words) Please include letters of support from the school(s), if available.

4. COMMUNITY SUPPORT AND ONGOING ENGAGEMENT

Is a consultation report attached?8 Yes. No.

Is a community engagement and liaison plan attached?9 Yes. No.

Please list the stakeholders or organizations that have submitted letters of support and include attachments (Maximum 200 words):

8 Please refer to Section 4 of the CTS Application Guide 9 Please refer to the Accountability section of the CTS Application Guide

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5. ACCESSIBILITY

Does the site meet municipal bylaws? Yes. No.

Is the proposed CTS compliant with the Accessibility for Ontarians with Disabilities Act? Yes. No.

Please describe how the services offered are culturally, demographically, and gender appropriate (Maximum 150 words):

Please describe how the proposed CTS is strategically located (i.e. walking distance from where open drug use is known to occur) (Maximum 150 words):

Please describe the transit accessibility of the proposed CTS site (Maximum 150 words):

6. BUDGET

Is a proposed operating budget attached? Yes. No.

Is a provisional capital budget attached (if applicable)? Yes. No.

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SIGNATURES I verify the information provided on this form is correct.

Print Name of Applicant(s) Signature Date

SUBMITTING AN APPLICATION / REQUESTING INFORMATION Completed Consumption and Treatment Service application forms and accompanying documents should be submitted to: Addiction and Substances Policy and Programs Unit Health Improvement Policy and Programs Branch Population and Public Health Division Ministry of Health and Long-Term Care Email: addictionandsubstances@ontario.ca