To be completed by all new participants who engage in Mosaic Zoom programs
Name of Person Filling Out Form
First Name
Last Name
Name of Participant (In subsequent questions, "you" refers to participant named here)
First Name
Last Name
What name do you prefer to be called by?
Gender of Participant
*
Male
Female
Prefer not to say
Birth Date of Participant
*
-
Month
-
Day
Year
Date
Phone Number
*
-
Area Code
Phone Number
Can we text you on this number?
*
Yes
No
Email
example@example.com
Do you check email regularly?
*
Yes
No
How do you prefer to be contacted
Email
Phone Call
Text Message
U.S. Mail
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Address (if different from Mailing Address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Tell us about your living status (check all that apply):
*
I live alone
I live with a roommate
I live with a spouse
I live with my parents or grandparents
I live in a supported living house
I live with a sibling
Other
What do you enjoy doing? e.g. video games, walking, dancing, watching movies, playing board games, hanging out with friends, etc.
*
What technologies can you use WITHOUT assistance?
*
Smart Phone
Computer
Tablet
NONE
Other
What technologies can you use WITH assistance?
*
Smart Phone
Computer
Tablet
NONE
Other
Do you have someone who can help you with using technology tools?
*
Yes, always
Yes, sometimes
No
I don't need assistance, I am self-sufficient using technology tools
Do you have someone who can help you with accessing Mosaic's Zoom programs?
*
I don't need assistance, I am self-sufficient in using Zoom
Yes, a family member
Yes, a care provider
Yes, Other
No, I do not have anyone who can help me with using Zoom
Do you have any sensitivities that we should be aware of as we provide Virtual Mosaic services? (check all that apply)
*
Yes, I am sensitive to lights
Yes, I am sensitive to noise
Yes, I get easily agitated
Yes, I get frustrated easily
Yes, My feelings get hurt easily
Yes, It takes a lot for me to get engaged
No
Please provide any additional information that can help us to serve you via Zoom, e.g. calming techniques, ways to engage you, etc. (type "NA" if you have no suggestions)
*
What is your reading level?
*
Do not read or write
Recognize letters & numbers
Recognize some sight words
Limited phonics-based reading ability
Elementary level
High School level
Name of your DDA Case Manager
First Name
Last Name
Case Manager Phone Number
-
Area Code
Phone Number
What DDA waiver are you on?
*
Basic Plus
Individual and Family Services (IFS)
Core
Other
I don't know
I am not on a DDA waiver
Emergency Contact
*
First Name
Last Name
Emergency Contact #
*
-
Area Code
Phone Number
How is your Emergency Contact related to you?
*
Parent
Sibling
Other family member
Unpaid care provider, non-family
Paid care provider
Neighbor
Friend
Other
Submit
Should be Empty: