• Universal Residential Application

    Universal Residential Application

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  • Instructions for completion:

  • Consistent with System of Care principles, the Universal Child and Adolescent Residential Application offers a comprehensive clinical review of a member's needs for purposes of admission to a residential provider contracted with Vaya Health. Please follow the instructions below:

    1. This application, including all sections, must be completed in its entirety. Answer each question, indicating "N/A" if not applicable. Applications may be returned to referring party if deemed incomplete.

    2.Do not enter "see attached" in sections requiring specific detail. If you have a document that provides greater detail than can be entered, reference the document name, date and page number at the end of your explanation. (e.g., Physical Assessment, 07.01.15, page 3). Submit any reference documentation along with this application.

    3.The person completing this application is responsible for obtaining necessary releases/authorizations to disclose protected health information.

    4.The Universal Application must be signed by the legally responsible person as defined at N.C.G.S. § 122C-3(20): "a parent, guardian, a person standing in loco parentis, or a legal custodian other than a parent who has been granted specific authority by law or in a custody order to consent for medical care, including psychiatric treatment."

    Disclaimer: This form was created for the convenience of referring agencies/individuals to streamline discharge planning and eliminate time and redundancy associated with multiple agency-specific applications. Use of this form does not, and should not be construed to, guarantee authorization of residential or other treatment by Vaya. Moreover, responsibility for appropriate discharge from inpatient facilities remains with the discharging provider.

  • Date of application*
     / /
  • Date service needed*
     / /
  • Type of referral/Level of Care sought*

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    Vaya Health | Universal Residential Placement Application

    Provider Network | Rev. 02.20.2019

  • 1. Member Demographic Information

  • Date of birth*
     / /
  • Sex
  • Format: (000) 000-0000.

  • 2. Legally Responsible Person Information

  • Is the minor under the care and custody of his or her parent?*
    • If yes, click next section. If no click here to expand. 
    • Is there a legal guardian/legal custodian appointed by a court of competent jurisdiction?

    • (If yes, attach copy of court order)

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    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Is there an individual acting in loco parentis (such as another relative)?
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.

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      Vaya Health | Universal Residential Placement Application

      Provider Network | Rev. 02.20.2019

  • 3. Family Information

  • Biological parents are*
  • Have parental rights been terminated?*
  • Is the member adopted?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of birth
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of birth
     / /

  • Sibling or other significant relationship:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Additional sibling or other significant relationship:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Are any "no contact" orders currently in place?
  • Are any special conditions/restrictions for home visits in place?

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    Vaya Health | Universal Residential Placement Application

    Provider Network | Rev. 02.20.2019

  • 4. Family Dynamics/Family Social History

  • If other pertinent family history exists, please document separately and attach.

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  • 5. Referral Source Information

  • Referring agency*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

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    Vaya Health | Universal Residential Placement Application

    Provider Network | Rev. 02.20.2019

  • 7. Clinical/Diagnostic Information

  • Rows
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  • Has member received a psychological evaluation?*
  • Exam date
     / /
  • Is the member diagnosed with an intellectual/developmental disability?*
  • Date
     / /
  • Date
     / /

  • 8. Medication Information

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  • Rows

  • 9. Treatment and Placement History

  • Rows

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    Vaya Health | Universal Residential Placement Application

    Provider Network | Rev. 02.20.2019

  • 10. Current Symptoms/Observations

  • Check all that apply.*
  • Abuse/trauma history*

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    Vaya Health | Universal Residential Placement Application

    Provider Network | Rev. 02.20.2019

  • 11. Risk Assessment

    Only fill applicable sections.
  • A) Self-injurious behavior. Check all that apply:
  • Has self-injury ever required medical attention?
  • B) Suicidal characteristics. Check all that apply:
  • Were attempts planned?
  • C) Homicidal characteristics. Check all that apply
  • Were attempts planned?
  • Does the member have access to weapons?
  • D) History of elopement. Check all that apply
  • E) Sexualized behavior. Check all that apply
  • F) Psychotic symptoms. Check all that apply

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    Vaya Health | Universal Residential Placement Application

    Provider Network | Rev. 02.20.2019

  • Rows

  • 13. Medical Information

  • Date of last physical exam*
     / /
  • Immunization status*

  • MEDICAL CONDITIONS (PAST AND PRESENT)

  • Most recent occurrence
  • Date of last dental exam*
     / /
  • Dental appliances*
  • Date of last eye exam*
     / /
  • Corrective lenses*

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    Vaya Health | Universal Residential Placement Application

    Provider Network | Rev. 02.20.2019

  • 14. Insurance Coverage

  • Health Insurance Coverage*

  • 15. Agency Involvement

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • 16. Educational/School Information

  • Current IEP?*
  • Date
     / /
  • Special classes
  • Does the member have a criminal record?
  • Is the member on probation?
  • Are there pending charges?
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  • Page 9 of 13

    Vaya Health | Universal Residential Placement Application

    Provider Network | Rev. 02.20.2019

  • 18. Daily Living Skills Information

    (Required for IDD and co-occurring IDD/MH referrals)
    • Eating: 

    • Eating:

    • Does the member eat solid foods?*
    • Does the member eat independently?*
    • Does the member require special accommodations?*
    • Is there a history of choking/overfilling mouth?*
    • Toileting: 

    • Toileting:

    • Is the member continent?*
    • Can the member use the bathroom alone?*
    • Does the member wear pull ups/diapers at night?*
    • Will member tell someone if bathroom is needed?*
    • Is the member on a toileting schedule?*
    • Sleeping: 

    • Sleeping:

    • Does the member usually sleep through the night?*
    • Walking: 

    • Walking:

    • Is the applicant ambulatory?*
    • If no, does the applicant use:
    • Does the equipment meet current needs?
    • Language: 

    • Language:

    • Is the member verbal?*
    • If no, click here. 
    • Does the member understand one- or two-word commands?
    • Does the member follow one/two-step commands?
    • Behavior: 

    • Behavior:

    • Does the member have a history of:
    • Does member usually hurt him/herself or others?*

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      Vaya Health | Universal Residential Placement Application

      Provider Network | Rev. 02.20.2019

  • 19. Strengths/Abilities/Preferences

  • 20. Treatment Goals

  • Identification of the service(s) being requested.
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  • 21. Additional Information (Required)

  • Page 11 of 13

    Vaya Health | Universal Residential Placement Application

    Provider Network | Rev. 02.20.2019

  • 22. Referral Checklist

    Please comment on if attached or reasons items are missing or items that will be sent at a later time
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  • Page 12 of 13

    Vaya Health | Universal Residential Placement Application

    Provider Network | Rev. 02.20.2019

  • SIGNATURES

  • Date
     / /
  • Date
     / /
  • Date
     / /

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    Vaya Health | Universal Residential Placement Application

    Provider Network | Rev. 02.20.2019

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