Pre-Admission Screening

Pine Castle Pre-Assessment Form

Participating in the pre-screening for individuals with intellectual and developmental differences for Pine Castle involves assessing the participant's abilities and needs. This process allows participants to communicate their unique requirements, strengths, and challenges. It's an opportunity for participants to share their preferences and expectations, ensuring that the staff at Pine Castle can provide the tailored support that best matches the participant's abilities and goals. Ultimately, this pre-screening empowers you to have a voice in shaping the caregiving experience to meet the participant's needs and enhance their overall well-being.

Please Take Photo of Participant

Name*

First NameLast Name

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Phone*

Please enter a valid phone number.

Secondary Phone

Please enter a valid phone number.

Funding Source*

Financial aid scholarships are available to those who qualify. Would you like to be considered for financial aid?

How Did You Hear About Pine Castle?*

What Date Do You Intend to Start?

Primary Disability*

Mental Health Diagnosis*

Do you need Mental Health Services*

Mental Health Insurance Provider*

Medical Insurance Provider*

Medicaid ID

Date of Birth*

Social Security Number*

Medical Insurance Provider*

The Academy Pathways

The Academy has two semesters per year, and participants can choose different courses and extra-curricular activities each semester. Both pathways include weekly field trips for up to ten participants in a small group setting utilizing our two campus buses. One bus is dedicated to the Pathway to Community Employment and includes job exploration field trips. The other bus is used for the Life Enrichment Pathway and incorporates cultural and civic outings.

Life Enrichment Pathway

Our Life Enrichment curriculum focuses on developing the life skills necessary to increase overall independence and quality of life for individuals with IDD through hands-on learning experiences. Individuals on the Pathway to Life Enrichment will complete the following modules: Personal Productivity, Money Management, Community Skills, Interpersonal Skills, Self-Advocacy and Health, Safety, and Citizenship.

Community Employment Pathway

Our Community Employment Pathway guides individuals seeking employment within the community to find the best-suited career path. Pre-screening will identify an individual’s needs, abilities, skill level, and interests. Training will be provided to help our participants obtain and maintain employment by transitioning them into work settings through the Academy curriculum. This pathway is time-limited; clients have 36 months to move through the path to obtain a job in the community.

Life Enrichment PathwayCommunity Employment Pathway

Pine Castle Assessment Scale:

Please answer the following questions on a 1 to 10 rating system where 1 represents the lowest number, and 10 signifies the highest level or intensity of a quality or attribute. Admissions will use this as part of the determination of placement within the student-to-staff ratios.

On a scale of 1-10 Does the participant require assistance, through instructional prompts, cues, and supervision to properly complete the basic personal care areas of eating, bathing, toileting, grooming, and personal hygiene.

Does the participant require prompts, supervision, and physical assistance to perform basic personal care tasks such as eating, bathing, toileting, grooming, transitioning, and personal hygiene.

Is the participant on a behavior services plan that is implemented by the ADT provider?

Does the participant exhibit the characteristics required for behavior focus residential habilitation services as outlined in the handbook and as determined by a certified behavior analyst?

Does the participant require an intense level of personal care support services? (For example, include assistance with eating, positioning, assistance with lifting, or total physical assistance.)

Psychosocial Rehabilitation Program (PSR):

As a part of our Psychosocial Rehabilitation Program (PSR), we help educate our participants on their co-occurring IDD and mental health conditions in a group setting. We work with participants to develop coping skills, reduce symptoms, improve relationships, and more. At Pine Castle, each PSR group is led by a Behavioral Health Technician and contains no more than 12 participants. We also offer Individual Counseling, using a client-centered therapeutic approach and various evidence-based practices to address concerns one-on-one.

Is this individual currently working with a Behavior Analyst?

Does this individual require assistance when using the restroom?

Does this individual require assistance when eating?

Can this individual transfer location independently? (For example, walk from one area on campus to the next without supervision?)

Does this individual require behavior intervention strategies?

Can they communicate wants and needs without behaviors?

Can they accept no/redirection without behaviors?

Does this individual require assistance with a wheelchair or other adaptive equipment?

Can this individual complete age appropriate hygienic tasks independently?

What are your current concerns?

Signature

Once the form is submitted, someone from Admissions will be in contact with you within 24-48hrs. If you need immediate help you can contact Admissions at Admissions@pinecastle.org or 904.733.2650.

Privacy Statement: Your privacy is important to us. We collect personal information, such as your name and contact details, solely for the purpose of conducting a pre-screening for individuals with intellectual and developmental disabilities. This information ensures that the caregiver assigned to you meets your specific needs. We employ strict security measures to protect your data and retain it only for as long as necessary. Your information will not be shared without your consent, except as required by law. By submitting this form, you consent to the use of your data as outlined in this statement, and you can contact us for access or corrections to your information. Your privacy is our priority.

Pathway Choice