Project WILL Member Initial Application
Supp-Exp 1.2, Rev. 0, Date: 02/2022
General Information
Person Completing
First Name
Last Name
Applicant's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Current Living Situation
*
Alone
With Guardian
Supported Living
Other
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Parent/Guardian/Authorized Representative Information
Parent/Guardian/Authorized Representative Name
First Name
Last Name
Parent/Guardian/Authorized Representative Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
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Emergency Contact Infromation
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
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Applicant Primary Diagnosis
*
Additional Diagnoses (check all applicable items)
*
Intellectual Disability
Brain Injury
Autism Spectrum
Deafness or Hearing Impairment
Specific Learning Disability
Behavioral Disability
Communication Disorder
Orthopedic Impairment
Psychological Disability
Intellectual Disability
*
Mild
Moderate
Severe
Please Describe Specific Learning Disability
Please Describe Behavioral Disability
Please Describe Communication Disorder
Please Describe Orthopedic Impairment
Psychological Disability
*
Depression
Anxiety
Bi-Polar
Schizophrenia
Personality Disorder
Other
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Medical Concerns
Please Check All Applicable Items
*
No chronic medical conditions
Hearing impairment
Vision impairment
Seizure disorder
Specific dietary needs
Allergy to food
Allergy to bee stings
Allergy to medications
Environmental allergies
Other
Please Describe Hearing Impairment
*
Please Describe Vision Impairment
*
Seizure Disorder Type
Petit Mal
Grand Mal
Focal
Psychomotor
How is the seizure disorder controlled?
Completely controlled with medication
Somewhat controlled with medication
Not controlled with medication
Type option 4
Please Describe Unusual Behavior Before Seizure
*
Please Describe Unusual Behavior After a Seizure
*
Please Describe Specific Dietary Needs
*
Please Describe Food Allergy
*
Please Describe Bee Sting Allergy
*
Please Describe Medication Allergy
*
Please Describe Environmental Allergy
*
Does the Applicant use Assistive Devices such as
Wheelchair
Braces
Hearing Aid(s)
Glasses
Communication Devices
Braille Reader
Other
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Medications
Will you need to take any medication during program hours:
*
Yes
No
If Yes, Please Detail Below
*
Rows
Medication Name
Dose
Time
Route
Medication
Medication
Medication
Medication
Medication
Medication
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Waiver Information
Case Manager Name
*
First Name
Last Name
Case Manager Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Case Manager Email Address
*
example@example.com
Company
*
Please check all services you receive from other waiver providers
*
Behavior Support Services
Employment Services (Vocational Rehabilitation or ExtendedServices)
Musical or Recreational Services
Occupational Therapy
Self-Directed Services(Residential or Community Habilitation, respite, or PAC)
Name of Behavior Support Specialist
Name of Employment Specialist
Name of Music Therapist
Name of Recreational Therapist
Name of Occupational Therapist
Name of Agency
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Communication Skills
Please Check All That Apply
Communication Mode
*
Verbal
Communication Device
Sign
Gesture
No system to indicate
Expressive Language
*
No problem with articulation
Single words
Phrases and/or short sentences
Asks for assistance when needed
Receptive Language
*
Understanding what is being said
Makes eye contact
Follows one-step instructions
Follows multi-step instructions
Additional comments regarding communication
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Behavioral Concerns
Please complete all that apply
Rows
Describe Behavior
Frequency
Aggression
Anxiety
Depression
Elopement
Physical Aggression
Property Destruction
Self-injurious
Self-stimulating
Sexual Inappropriate Behavior
Verbal Aggression
Previous Criminal Activity
Other
Additional comments regarding behaviors
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Social/Emotional Development
Check all that apply
*
Rows
Yes
No
Is relatively free from signs of problems
Understands what is being said
Makes eye contact
Follows multi-step directions
Shows anger appropriately
Resists cooperation
Interacts appropriately with staff
Interacts appropriately with peers
Interacts appropriately with animals
Doesn't interact, even when encouraged
Appears to have significant emotional problems
Expresses feelings/needs verbally
*
Yes
No
Please describe how the member expresses feelings/needs (Sing, Comm Device, Gestured, etc.)
*
Difficulty with expressive language
*
Yes
No
Please describe specific difficulty (Uses single words, short phrases, difficulty with articulation, etc.) and interventions used to understand speech.
*
Prefers the company of:
Males
Females
Children
Adults
No Preference
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Transportation
Check the appropriate yes/no boxes
Rows
No
Yes
Describe
Utilizes public transportation
Adaptive equipment required while riding in vehicle
Special seating arrangements while riding in vehicles
Depends on others
Can schedule rideshare independently
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Education
Name of School:
City, State
Highest Education Level Completed
Number of Years Attended
Teacher of Record/Transition Coordinator
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Vocational Experiences
Please
Rows
No
Yes
If yes, please describe
Paid Work
Unpaid Work
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Desired Outcomes
What are you hoping to accomplish by participating in this program?
Goal 1
Rows
Please complete
Goal #1
Objective #1
Objective #2
Goal 2
Rows
Please complete
Goal #2
Objective #1
Objective #2
Goal 3
Rows
Please complete
Goal #3
Objective #1
Objective #2
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Additional Comments
Waiver InformationThe information in this document is confidential and will only be used by Project WILL, Inc. for application purposes. My signature verifies that all of the information is true and valid to the best of my knowledge.
Signature of Member
Member Signature Date
Signature of Parent/Guardian/Other Authorized Representative
Parent/Guardian/Other Authorized Representative Signature Date
Submit
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