Application for Admission

Application for Admission
Applicant's Name:*

First NameLast Name
Email:*
example@example.com
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Contact Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Applicant's Gender:*
Applicant's Birth Date:*

MonthDayYear
Where does applicant reside?*

With Parent(s)With Other Family Member(s)Group Home/Residential Living ArrangementLives Independently/Own Home
Does Applicant receive Medicaid waiver services/funding (such as CLASS, TxHML, or HCS, etc)?*
If you replied "Yes" above, which Direct Service Agency do you use (e.g. Astrocare, Perry Lee, Touch of Class, etc.)?
Family Information
Mother's Name:*

First NameLast Name
Mother's Email:*
example@example.com
Mother's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Preferred Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Mother's Occupation/Place of Employment:*
Does Mother have legal guardianship of the Applicant?*

YesNo
Father's Name:*

First NameLast Name
Father's Email:*
example@example.com
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Preferred Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Father's Occupation/Place of Employment:*
Does Father have legal guardianship of the Applicant?*

YesNo
Other Caregiver's Name:*

First NameLast Name
Caregiver's Relationship to Applicant:*
Caregiver's Email:*
example@example.com
Caregiver's Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Does this person have legal guardianship of the Applicant?*

YesNo
Emergency contact in case parent(s)/guardian may not be reached:*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Email Address:*
example@example.com
Names/Ages of Applicant's Siblings:*
Please attach current photo of Applicant:*

Cancelof
Please indicate all other programs in which Applicant has participated:*

Public or Private High SchoolPost High School Educational ProgramDay Hab/Activity CenterGroup HomeCompetitive EmploymentVolunteer WorkOther
Names/dates of programs indicated above:*
Medical Information
Please describe Applicant's diagnoses, general state of health, and MEDICAL ISSUES: Allergies/Epi-Pen, abdominal condition, seizures, asthma, diabetes, heart condition, blood disorder, menstrual concerns, ear/nose/throat, visual, hearing, incontinent, kidney issues, fainting spells, dietary needs, etc.), BEHAVIORAL ISSUES (fears, phobias, dislikes, triggers, aggression, elopement, etc), and PHYSICAL DISABILITIES (braces, walker, wheelchair, etc). Be specific.*
Please list all medications Applicant currently takes; include purpose of the medication, frequency, dosage and prescriber's name: Will Applicant need to take medication during the day while at Together?*
Name of Applicant's primary physician:*
Physician's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Physician's Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Has Applicant had surgery(ies) and/or been hospitalized? For what? When?*
Please list any other medical specialists or therapists who are treating (or have treated) the Applicant. Include name(s), speciality(ies), address(es), email and phone number(s):*
Abilities

Social, Behavioral, Communication
Please describe Applicant's communication abilities (e.g. verbal, non-verbal, gestures, communication device, communication board, picture reminders, etc.):*
Please describe Applicant's temperament most of the time: (e.g. easy-going, shy, talkative, loner, angry, impulsive, emotional, social, happy, etc.):*
Please describe Applicant's social preferences (e.g. being with family, peers, friends, older or younger people or alone):*
Please describe Applicant's self-help skills (e.g. Will Applicant need assistance with eating/drinking, toileting, dressing, transferring, walking (wheelchair use), accessing work equipment/materials, etc.?) *
What types of leisure or social activities does Applicant enjoy? What are Applicant's daily routines?*
Please describe Applicant's strengths and interests.*
What would Applicant (or you) say are his/her biggest challenges or things he/she may struggle with:*
Please describe activities or situations that Applicant dislikes or which may trigger behavior issues. What are the most effective ways to address behavior issues or ways to comfort and calm the Applicant? Feel free to attach Behavior Plan, if applicable.*
Attach Behavior Plan (if applicable)

Cancelof
Has Applicant been involved with any of the following:*

Tobacco/SmokingPrescription or illegal drug abuseCriminal activitySexual misconduct/inappropriate behaviorViolence/aggressive/physically harmful behaviorVerbally abusive behaviorSelf-injurious behaviorImpulsivity or ObsessionsOther
If yes, please explain:
Please describe any activities in which Applicant may not participate or any specific restrictions Applicant may have:*
Your Expectations for Applicant

Authorizations and Additional References
What are your goals and expectations for the Applicant while learning and working at Together?*
Please provide any additional information you would like us to know about the Applicant:*
Please list 3 other individuals who have worked with or known the Applicant closely who we may contact to discuss Applicant's suitability for Together at Mikey's Place. Include names, phone numbers, addresses, email, and relationship to Applicant:*
I/We affirm that the preceding information represents true and accurate facts regarding Applicant's circumstances for consideration of enrollment in Together at Mikey's Place.*

I/We affirmI/We do not affirm
I/We, the undersigned, give our permission to Together at Mikey's Place to contact any and all of the references, individuals, programs, schools, and physicians listed in this application for information regarding the Applicant.*

I/We grant our permissionI/We do not grant our permission
I/We authorize anyone who has any information about Applicant to release said information they may have to Together at Mikey's Place.*

I/We authorizeI/We do not authorize
Copies of this application and release of information may be used to obtain information from anyone listed on this application for acceptance into Together at Mikey's Place.*

YesNo

My Products

Application Fee

One-time, non-refundable fee

$50.00

Total

$0.00

Credit Card

Should be Empty:

Application for Admission

Family Information

Medical Information

Abilities

Your Expectations for Applicant

Credit Card