Application for Services Step 1 of 5 20% IdentificationDate* Date Format: MM slash DD slash YYYY Applicant's Name* First Middle Last Preferred Name First Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Sex*MaleFemaleWeightHeightDate of Birth* Date Format: MM slash DD slash YYYY AgeMarital StatusSingleMarriedDivorcedSeparatedCurrent Living ArrangementsReligious AffiliationChurchPastorSupport CoordinatorSupport Coordinator's Phone NumberAgencyEmail Address Contact Person*Relationship*Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumberEmail Emergency Contact*Relationship*Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumberEmail Medical and DentalAll Current Diagnoses*PhysicianPhoneDate of Last Physical Exam Date Format: MM slash DD slash YYYY DentistPhoneDate of Last Dental Exam Date Format: MM slash DD slash YYYY Condition of TeethExcellentGoodFairPoorMedicationsCurrent MedicationReasonDosageFrequencyPrescribed By Allergies or Special Medical Conditions*Diet*RegularModifiedSpecialPlease explain:Does food need to be cut?*YesNoPhysical Impairments (Check all that apply):* Blind Deaf Non-Verbal Cerebral Palsy Semi-Ambulatory Non-Ambulatory Other Does applicant know sign language?YesNoExplain other:Seizure History*NoYesHow often?What type?Date of last seizure: Date Format: MM slash DD slash YYYY Special Adaptive Devices (Check all that apply): Wheelchair Crutches Orthopedic or Special Shoes Adaptive Eating Utensils Hearing Aid Other Explain Adaptive Utensils:Explain Other: Assessment of SkillsHow does applicant walk?*IndependentlyRequires AssistanceTotally DependentHow does applicant dress self?*IndependentlyRequires AssistanceTotally DependentApplicant's toileting?*IndependentRequires AssistanceTotally DependentHow does applicant feed self?*IndependentlyRequires AssistanceTotally DependentHow does applicant bathe self?*IndependentlyRequires AssistanceTotally DependentHow does applicant wash hair?*IndependentlyRequires AssistanceTotally DependentHow does applicant brush teeth?*IndependentlyRequires AssistanceTotally DependentHow does applicant tell time?*IndependentlyRequires AssistanceTotally DependentHow does applicant make bed?*IndependentlyRequires AssistanceTotally DependentHow does applicant shave?*IndependentlyRequires AssistanceTotally DependentApplicant's menses care?IndependentRequires AssistanceTotally DependentHow does applicant understand numbers?*IndependentlyRequires AssistanceTotally DependentHow does applicant handle money?*IndependentlyRequires AssistanceTotally DependentHow does applicant use leisure time?*IndependentlyRequires AssistanceTotally DependentHow does applicant cook meals?*IndependentlyRequires AssistanceTotally DependentList significant likes of applicant:List significant dislikes of applicant:List recreational activities and hobbies applicant enjoys:What does applicant do when angry?Explain behavioral problems or concerns. Describe and list frequency: Type of Service NeededWhich type of service are you applying for?*Group HomeGroup Home for FutureSemi-Independent Living ArrangementEstimated Date Date Format: MM slash DD slash YYYY Explain why the applicant needs services at this time, or if applicant anticipates need for services at a future date.*Services ReceivedList all developmental or mental health services received by the applicant. Include both institutional and community services with addresses. (Ex: state hospital, day training center, etc.)*Vocational/Training HistoryList all vocational training and job experience, if any, that the applicant has received, with name and address of agencies or companies.* FinancialDoes applicant have a legal court appointed guardian?*YesNoDate of Court Order Date Format: MM slash DD slash YYYY State of Court Order AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Guardian of PersonAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Guardian of Financial Affairs/EstateAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How are the applicant’s day-to-day financial needs presently being met?*Does the applicant receive: Supplemental Security Income Social Security Disability Benefits Social Security VA Benefits Other Supplemental Security Income Amount:Social Security Disability Benefits Income Amount:Social Security Income Amount:VA Benefits Income Amount:Other:Other Income Amount:Whose Social Security payments does the applicant draw from?Their ownParentParent/Guardian's Name:Person responsible for medical expenses:Relationship to applicant:Parent/GuardianRepresentativeOtherIs applicant eligible to receive Medicaid?*YesNoIs applicant eligible to receive Medicare?*YesNoIs applicant covered by personal health insurance?*YesNoName of Insurance CompanyAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Subscriber of Policy First Last Does applicant have any other insurance policies (Ex: Life, Champus, Railroad Retirement, etc.)?*YesNoPurchaser of PolicyType of Insurance (health, life, etc.):Name of CompanyPhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State If life insurance, is policy for burial of applicant?YesNoIs policy paid up?YesNoBeneficiaryFace ValueAre there any other provisions for burial?*YesNoDoes applicant have a Trust Fund set up for their behalf?*YesNoSignature of person filling out application* First Last Relationship to applicant*Date* Date Format: MM slash DD slash YYYY
