Application for Admission
Applicant's Name:
*
First Name
Last Name
Email:
*
example@example.com
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Contact Phone Number:
*
Please enter a valid phone number.
Applicant's Gender:
*
Applicant's Birth Date:
*
Please select a month
January
February
March
April
May
June
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August
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Month
Please select a day
1
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Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
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2016
2015
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Year
Where does applicant reside?
*
With Parent(s)
With Other Family Member(s)
Group Home/Residential Living Arrangement
Lives Independently/Own Home
Does Applicant receive Medicaid waiver services/funding (such as CLASS, TxHML, or HCS, etc)?
*
Please Select
Yes
No
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 Name
Last Name
Mother's Email:
*
example@example.com
Mother's Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Preferred Phone Number:
*
Please enter a valid phone number.
Mother's Occupation/Place of Employment:
*
Does Mother have legal guardianship of the Applicant?
*
Yes
No
Father's Name:
*
First Name
Last Name
Father's Email:
*
example@example.com
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's Preferred Phone Number:
*
Please enter a valid phone number.
Father's Occupation/Place of Employment:
*
Does Father have legal guardianship of the Applicant?
*
Yes
No
Other Caregiver's Name:
*
First Name
Last Name
Caregiver's Relationship to Applicant:
*
Caregiver's Email:
*
example@example.com
Caregiver's Phone Number:
*
Please enter a valid phone number.
Does this person have legal guardianship of the Applicant?
*
Yes
No
Emergency contact in case parent(s)/guardian may not be reached:
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Emergency Contact Email Address:
*
example@example.com
Names/Ages of Applicant's Siblings:
*
Please attach current photo of Applicant:
*
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Please indicate all other programs in which Applicant has participated:
*
Public or Private High School
Post High School Educational Program
Day Hab/Activity Center
Group Home
Competitive Employment
Volunteer Work
Other
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
City
State / Province
Postal / Zip Code
Primary Physician's Phone Number:
*
Please enter a valid phone number.
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)
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Has Applicant been involved with any of the following:
*
Tobacco/Smoking
Prescription or illegal drug abuse
Criminal activity
Sexual misconduct/inappropriate behavior
Violence/aggressive/physically harmful behavior
Verbally abusive behavior
Self-injurious behavior
Impulsivity or Obsessions
Other
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 affirm
I/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 permission
I/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 authorize
I/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.
*
Yes
No
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Application Fee
One-time, non-refundable fee
$
50.00
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