Edmonton Fetal Alcohol Network

Quality of Life Barrier Reduction Fund

This fund was created for individuals ages 6 – 24 diagnosed with Fetal Alcohol Spectrum Disorder and a mental health disorder, to provide these youth and young adults with the opportunity to fulfill their potential.

How to apply for HelpYou will need to fill out this application and send it into the Edmonton Fetal Alcohol Network by the 28th of the given month.

Edmonton Fetal Alcohol Network#2 9137 Jasper Ave

Edmonton, ABT5H 3T2

Email: Lisa.Rogozinsky@catholicsocialservices.ab.caBrittani.Patten@catholicsocialservices.ab.ca

Fax: 780-477-2499

Allocation of the funds will be based on the completion of our Quality of Life Framework Chart location on page 3 of this document. The chart will be used to help paint a picture for the Network as to how the funds will enhance the applicant’s quality of life. More information on each of the categories is located on page 4 of this document.

Applications can be made prior to the 28th of each month but they will only be voted on at the Network Meeting, which falls on the first Tuesday of each month.

Applicants must demonstrate that they have a FASD diagnosis as well as a mental health diagnosis.

Applicants must be between the ages 6 – 24. It is expected that applying agencies be active members of the Edmonton Fetal Alcohol

Network. Description of the complex behavior that will be address with funds must be provided. For fairness and transparency to all, the barrier reduction fund is available on a first come

first serve basis. It is expected that the barrier reduction fund will have a limited life span (until the period

is complete or the funds have been exhausted). It is important to note that the applying agency will be required to pay upfront for the

approved expenditure and must provide the original receipt within 30 days to be reimbursed for the cost.

Edmonton Fetal Alcohol NetworkBarrier Reduction Fund

(Agency information will be used for contact purposes; client information will be used only for evaluation and statistical purposes. Any identifying information will not be released to the Network.)

a) APPLICANT INFORMATION

Name of Applying Agency:Agency Contact:Phone Number: Relationship of Contact to Client:Address of Agency:Approved By (Agency Manager/Supervisor) Name:

Client Name:Client Birthdate:Client Address:

FASD Diagnosis: YES NO Where did the diagnosis occur (Clinic & Doctor)?

Mental Health Diagnosis :Where did the diagnosis occur (N/A if Addiction)?Complex Behaviors to be addressed with funding:

b) FUNDING REQUEST: Please specify the amount of funding requested and detail how the funds will be utilized.

QUALITY OF LIFE FRAMEWORK EVALUATION CHARTComplete the “Current” column of this chart to demonstrate how the distribution of funds would increase the level of well being in the domains that apply. Progress of the domains must be provided at 2 month and 4 month within the respective column (please use the same initial form sent in). The Quality of Life Framework on page 4 should be used as a reference.

DOMAIN CURRENT 2 MONTH 4 MONTH

EmotionalWell-Being

Material Well-Being

Physical Well-Being

Personal Development

Self-Determination

Interpersonal Relations

Social Inclusion

Rights

The Quality of Life FrameworkThe My Life: Personal Outcomes IndexTM is one way to measure personal outcomes for individuals with developmental disabilities. It is a survey that profiles how individuals feel about their quality of life in eight different domains. FACTORS and DOMAINS