Application for Services Step 1 of 5 20% IdentificationDate* MM slash DD slash YYYY Applicant's Name* First Middle Last Preferred Name First Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Sex* Male Female Weight Height Date of Birth* MM slash DD slash YYYY Age Marital Status Single Married Divorced Separated Current Living Arrangements Religious Affiliation Church Pastor Support Coordinator Support Coordinator's Phone NumberAgency Email Address Contact Person* Relationship* Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumberEmail Emergency Contact* Relationship* Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumberEmail Medical and DentalAll Current Diagnoses*Physician PhoneDate of Last Physical Exam MM slash DD slash YYYY Dentist PhoneDate of Last Dental Exam MM slash DD slash YYYY Condition of Teeth Excellent Good Fair Poor MedicationsCurrent MedicationReasonDosageFrequencyPrescribed By Allergies or Special Medical Conditions*Diet* Regular Modified Special HiddenPlease explain:Does food need to be cut?* Yes No Physical Impairments (Check all that apply):* Blind Deaf Non-Verbal Cerebral Palsy Semi-Ambulatory Non-Ambulatory Other HiddenDoes applicant know sign language? Yes No HiddenExplain other:Seizure History* No Yes HiddenHow often? HiddenWhat type? HiddenDate of last seizure: MM slash DD slash YYYY Special Adaptive Devices (Check all that apply): Wheelchair Crutches Orthopedic or Special Shoes Adaptive Eating Utensils Hearing Aid Other HiddenExplain Adaptive Utensils:HiddenExplain Other: Assessment of SkillsHow does applicant walk?* Independently Requires Assistance Totally Dependent How does applicant dress self?* Independently Requires Assistance Totally Dependent Applicant's toileting?* Independent Requires Assistance Totally Dependent How does applicant feed self?* Independently Requires Assistance Totally Dependent How does applicant bathe self?* Independently Requires Assistance Totally Dependent How does applicant wash hair?* Independently Requires Assistance Totally Dependent How does applicant brush teeth?* Independently Requires Assistance Totally Dependent How does applicant tell time?* Independently Requires Assistance Totally Dependent How does applicant make bed?* Independently Requires Assistance Totally Dependent How does applicant shave?* Independently Requires Assistance Totally Dependent HiddenApplicant's menses care? Independent Requires Assistance Totally Dependent How does applicant understand numbers?* Independently Requires Assistance Totally Dependent How does applicant handle money?* Independently Requires Assistance Totally Dependent How does applicant use leisure time?* Independently Requires Assistance Totally Dependent How does applicant cook meals?* Independently Requires Assistance Totally Dependent List 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 Home Group Home for Future Semi-Independent Living Arrangement HiddenEstimated Date 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?* Yes No HiddenDate of Court Order MM slash DD slash YYYY HiddenState of Court Order AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State HiddenGuardian of Person HiddenAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code HiddenGuardian of Financial Affairs/Estate HiddenAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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 HiddenSupplemental Security Income Amount:HiddenSocial Security Disability Benefits Income Amount:HiddenSocial Security Income Amount:HiddenVA Benefits Income Amount:HiddenOther: HiddenOther Income Amount:HiddenWhose Social Security payments does the applicant draw from? Their own Parent HiddenParent/Guardian's Name: Person responsible for medical expenses: Relationship to applicant: Parent/Guardian Representative Other Is applicant eligible to receive Medicaid?* Yes No Is applicant eligible to receive Medicare?* Yes No Is applicant covered by personal health insurance?* Yes No HiddenName of Insurance Company HiddenAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State HiddenSubscriber of Policy First Last Does applicant have any other insurance policies (Ex: Life, Champus, Railroad Retirement, etc.)?* Yes No HiddenPurchaser of Policy HiddenType of Insurance (health, life, etc.): HiddenName of Company HiddenPhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State HiddenIf life insurance, is policy for burial of applicant? Yes No HiddenIs policy paid up? Yes No HiddenBeneficiary HiddenFace Value Are there any other provisions for burial?* Yes No Does applicant have a Trust Fund set up for their behalf?* Yes No Signature of person filling out application* First Last Relationship to applicant* Date* MM slash DD slash YYYY
