Intake Application & Assessment:
Application Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medicaid Number
*
Individuals Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date Of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Please Select
Male
Female
Parent/Guardian Name
*
First Name
Last Name
Preferred Method Of Contact
*
Please Select
Phone
Email
Both
E-mail
example@example.com
Phone Number
*
Format: (000) 000-0000.
Target Population Diagnosis
*
Rows
Present
Serious Emotional Disturbance (SED)
Moderate Intellectual Disabilities
Medically Fragile (MEDF)
Developmental Disabilities (DD) & Medically Fragile (MEDF)
Autism
Intelligent Disability
Seizure
Other Diagnosis
Type of Residence
*
Please Select
Family
Agency
If Agency was selected, please provide the name and contact information of the agency
Does this person have a legal guardian (automatic if under 18, if not, please obtain documentation) If yes, please write name, address and phone/email
*
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Advocate Information
Name of Primary Caretaker
*
Relationship
*
Address (if different than above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Next
Care Management Information
Name of Care Management Organization (ACA, Tri-County, etc)
*
Name of Care Manager
*
Care Manager Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Care Manager Email
example@example.com
What services are you interested in exploring with UCCS (Please select all that applies) HCBS Services
*
Rows
Interested
Day-Habilitation
Community-Habilitation
In-Home Respite
After School Respite
Holiday Respite
Saturday Respite
Summer Camp
Other
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Medical Information
Does the individual currently or have a history of any pertinent medical conditions (i.e seizure disorder, hypertension, diabetes, etc...)
*
Does the individual have any special health care needs that we should be aware of? (i.e known allergies to foods/drugs special diet orders, etc)?
*
Please Select
No
Yes
If Yes, please provide detailed information
Is the individual able to report pain
*
Please Select
No
Yes
If No, how will we know if the individual is not feeling well?
Does the individual take any medications
*
Please Select
No
Yes
If Yes, what medications do they take (Please include dosage)
Name of the Primary Care Physician
First Name
Last Name
Physician's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Physician's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Medical Information
Name of Psychiatrist
First Name
Last Name
Psychiatrist's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Psychiatrist Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact (Who do we contact in case of an emergency)
*
First Name
Last Name
Relationship
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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School/Past Programs
Is the Individual Currently in School?
*
Please Select
Yes
No
If yes, what is the name of the School
Address of The School
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please list current and past day program affilitations:
School/Agency 1
School/Agency 1 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School/Agency 2
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Behavioral Assessments
Has the Individual ever participated in any type of community/ volunteer services program in the past? If yes please describe
What kind of activities/tasks does the individual prefer to participate in (i.e clerical, work, maintenance, custodial, independent, computer related, etc...)
Has the individual ever participated in an employment program? If yes, please provide details about the type of employment, agency, affiliation and reason for leaving the position
*
Behavioral Information: Does the individual exhibit or have a history of exhibiting any of the following behavioral difficulties? Please select all that applies.
*
Rows
Exhibits
Self-Injurius Behaviors
Self-Stimulatory
Behaviors
Elopement
Physical Aggression (towards others)
Taking things that belong to others
Talking to strangers
Verbal Aggression
Sexually Assertive Behavior
Echolalia
PICA (Ritualistic Behaviors)
Making False Statements
Other Behaviors
For all areas checked, please provide more details
What should we do when the individual is upset, frustrated etc, to help them regain control and/or feel better (i.e talk with them, give personal space, listen to music, etc)
What types of reinforcement/motivation to use with the individual (verbal praise, taking a break , computer time, etc)
Does the individual currently possess independent travel skills
*
Please Select
Yes
No
If yes, what is the extent of their travelling abilities? (i.e are they able to take the train independently? or are they only able to travel by bus)
What level of supervision does this individual require while out in the community and why?
*
Are there any environmental issues that would be important for us to know? (i.e sensitive to loud noises, doesn't like crowds, fears or phobias, etc) Please explain
Are there any other things you would like to share that you think it is important that we know in order to provide the proper care for your loved one? Please explain.
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
*
Submit
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