Language
English (US)
Spanish (Latin America)
Today' s Date
*
/
Month
/
Day
Year
Date
Case manager if known
Person Completing Form
Name
*
First Name
Last Name
Phone
*
Format: (000) 000-0000.
Email
*
example@example.com
How are you related to client?
*
Are you authorized to consent for this individual's healthcare?
*
Please Select
yes
no
Are You Currently Receiving Services Thru Another Company? (Such As Respite/Community Connector/ Homemaker/ Message Therapy ETC.)
*
Please Select
YES
NO
If Yes, Which Company?
Why Are You Leaving?
Client Information
Client's Name
*
First Name
Last Name
Gender
Please Select
Male
Female
Non-bianary
Birthdate
*
/
Month
/
Day
Year
Date
Medicaid number
*
SSN
Address, City, State & Zip Code
*
Primary Language
Primary Insurance Carrier
Plan Number
Secondary Insurance Carrier
Plan Number
Living Situations
Describe the client's current living situation and any recent changes.
Others in the household names and ages
School Name
School District
Grade Level
List any special services or accommodations your child is receiving at school.
*
School Teacher (name and contact)
ABA therapist (please include times services are provided)
Medical History
Primary Care Provider (name and contact)
*
Please describe any medications your child is currently taking (provide time and dosage)
*
List any allergies
*
Does the client have a history of seizures?
*
Please Select
yes
no
Date of last seizure?
Does the client wear glasses?
Please Select
yes
no
Does the client wear hearing aids?
Please Select
yes
no
diagnoses as relevant to waiver services (list date of last evaluation for each)
*
Family history of learning, motor, speech, or other developmental delays?
Adoption
Is your client aware of adoption
Please Select
yes
no
Age of adoption
Previous home experiences prior to adoption
Health and Safety
Is client able to use the restroom without assistane?
*
Please Select
yes
no
Does the client ever elope (run from you or others)
*
Please Select
yes
no
If yes please describe the situations in which trigger elopement
How do you handle discipline issues with the client at home?
Does the client have tantrums?
Please Select
yes
no
Please describe the nature of tantrums (causes, what they look like, etc.)
How does the client handle changes or variations in routine?
Describe the clients technology use and your preference in using it during care sessions.
List clients preferences and strengths
Client Service Information
List clients likes and dislikes
Describe the clients interaction with peers
What are your current concerns for the client?
What services are you currently interested in?
Respite Care
Community Connector
Homemaker
Massage therapy
Parent provider
Type of Waiver Applying For?
CES
CHRP
SLS
FSSP
CWCHN
Unsure
List times and days you would like each service completed?
Communication Method: Ex: Verbal, Non-Verbal, ASL, Spanish, Speech Device
Emergency Contacts
Emergency Contact Name and Number #1
Emergency Contact Name and Number #2
Submit
How did you hear about us?
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