Client Intake Form

Client Intake Form

2026
Full name of Individuals with Developmental Disabilities
Date of Birth

MonthDayYear
Date
Parent/Guardian Name

First NameLast Name
Please click the language that is best for you.
Preferred Language
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Preferred Method of Contact
Secondary Emergency Contact (Someone other than yourself)

First NameLast Name
Secondary Emergency Contact's Relationship to the Client
Secondary Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you currently receive services through another agency?
Child

What schedule will work best for this individual's needs?

Rows	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Time Needed

Additional Scheduling Needs
What are you looking for in a Direct Support Worker?
Direct Support Worker Gender Preference

Do any of these apply to the individuals requesting care?

Rows	Yes	No	Description
Aggressive Behavior
G-Tube
Nurse Delegation
Equipment Training (Lift, Bed, etc)
Medication Administration Record Sheet
Other (Please Describe)

Name of Case Manager and Email Address
Do you have a family member, friend, or someone else that is interested in being a support worker for your child? If so, please list their name and a way to contact them. Please note that workers need to meet a weekly 15 hour minimum to be onboarded.
If you know, please enter how many hours your child has through their Individual Support Plan
How did you hear about us?

Person Centered Plan

The purpose of this Plan is to create meaningful goals and a vision for each individual. Please fill this out for your child or for yourself in the case that you are an adult client of Out of the Box Solutions. This information will be shared with your support worker so please do not include any confidential information.
Photo (Optional)

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What yearly vision do you have for your child or yourself?
What are some yearly goals you would like to achieve?
What are some daily tasks your support workers can assist you with?
Do you have any weekly activities you'd like your support worker to assist you with?
Anything else to add:

Review of Services

Please read the following that will cover expectations and general agreement for services provided through Out of the Box Solutions. Following this information will guarantee higher quality of care and adherence to ISP and State regulations. This information is crucial as we work together to create an environment of success and progress.
ISP (Individual Support Plan)

As the parent or guardian, maintaining an up-to-date Individual Support Plan (ISP) for the client is crucial. We urge you to promptly inform Out of the Box Solutions of any issues that may impact the ISP renewal, such as potential loss of Medicare coverage or renewal difficulties. Failure to do so may lead to the responsibility of financially compensating the Direct Support Professional. To ensure a smooth renewal, please schedule evaluations at least one month before the ISP's expiration. For assistance or questions regarding the client's assessment, please contact us directly. Your proactive communication is essential in avoiding service interruptions and managing financial obligations efficiently.
Incident Report: As the parent/guardian of the client, you are responsible for reporting serious incidents to Out of the Box Solutions immediately, but no later than one business day after an incident happens. Below are the required reasons one must report.
- Significant Changes in Health Status: Unexpected or unexplained changes in the health status of an individual, including life-threatening conditions or hospitalizations.
- Serious Injury: Any injury that requires medical treatment beyond first aid, especially if it occurs under unusual or suspicious circumstances.
- Behavioral Incidents: Incidents involving aggressive or self-injurious behavior that results in injury or poses a significant risk to the individual or others.
- Person Receives emegerceny medical care and/or unplanned hospital visit
- Abuse or Neglect: Any suspicion or evidence of physical, emotional, sexual abuse, or neglect, including exploitation or abandonment.
- Person missing beyond the time frame established in their ISP
- Person admitted to a psychiatric hospital
- A safeguarding intervention or the use of safeguarding equipment including in a Positive Behavior Support Plan results in injury
- The use of physical restraint that is not included in the Behavior Support Plan
- Property Damage or Loss: Significant damage to or loss of property belonging to the individual receiving services, especially under suspicious circumstances
- Death: Any death of an individual receiving services, regardless of cause or circumstances.
- Rights Violations: Any situation where the rights of the individual receiving services are violated or threatened.
- Medication Errors: Errors in the administration of medication that could harm or have harmed the individual receiving services.
- Auto Accident
PBSP ( Positive Behavior Support Plan): If the client has a PBSP/FBA (Functional Behavior Assessment) listed in their ISP the following applies:
- As the parent/guardian you are responsible for ensuring that Out of the Box Solutions receives a copy of the most current BSP.
- As the parent/guardian you will be responsible for completing a one page Parental Guidance Support Plan (which will be provided to you upon the onboarding process) that outlines the BSP and how the DSP can best support the client.
- As the parent/guardian you will be responsible for communicating with Out of the Box Solutions if there is ever a change or update to the BSP. In the case of an updated BSP you are responsible to provide OOTBS with the updated plan.
Nurse Delegation: Delegation generally involves assignment of the performance of activities or tasks related to the client to unlicensed assistive personnel. Most of the time the ISP of the client will state if Nurse Delegation is required. (here are some examples/ but not limited to of when Nurse Delegation is required)
- G Tube
- Seizures
- Med administration (if through G tube)
- All Nurse Delegation will be required to be completed and the certificates turned into Out of the Box Solutions office prior to the DSP clocking hours
- All Nurse Delegation will be required to be completed and the certificates turned into the Out of the Box Solutions office prior to the DSP clocking hours
- Nurse Delegation is required every 6 months for all DSPS (with the exception of Permanent working parents of the client)
Medication Administration Record (MAR) Requirement: Should the Individualized Service Plan (ISP) indicate that medication is administered to the client by someone other than natural supports, a Medication Administration Record (MAR) must be established. In this scenario, the Direct Support Professional (DSP), with assistance from the parent/guardian, is tasked with the responsibility of meticulously tracking and documenting all administered medications, including dosages, times, and additional relevant details.
- The parent/guardian will be responsible for completing a Medication list for Out of the Box Solutions. This is required prior to any DSPs clocking hours (if the DSP is going to be handling any medication)
- The parent/guardian will be responsible for notifying Out of the BoxSolutions immediately if there is any medication change (if the DSP is going to be handling any medication)
- The parent/guardian will be responsible for updating the Medication list anytime there is an update and at the very least annually when the ISP is up for renewal
- Assisting DSP in accurately recording each medication administered to the client, including the name of the medication.
- Helping to document the correct dosages of each medication given.
- Aiding in tracking the specific times medications are administered.
- Ensuring that any side effects or reactions are noted in the MAR.
- Collaborating with the DSP to maintain a complete and updated record of all medications, to ensure compliance with the Individualized Service Plan (ISP).
Scheduling: As the Parent/Guardian you are responsible for the following:
- Monitoring Work Hours: Ensuring that the hours worked by the Direct Support Professional(s) (DSP) do not exceed those allocated in the Individualized Service Plan (ISP). Parents/Guardian are responsible to cover (pay) for shifts that are unable to be billed due to overlap or exceeding hours.
- Scheduling Oversight: Managing the scheduling of DSPs to prevent overlap and unauthorized extension of service hours, especially important when multiple DSPs are involved.
- Billing Awareness: Being mindful of the billing limitations and the necessity to align DSP working hours with what can be billed to avoid financial discrepancies with other agencies, please log into Wellskys "family room" to verify hours.
- Communication: Keeping open and clear communication with DSPs and the provider agency regarding any changes in scheduling or service needs to ensure compliance with the ISP.
- Contract Compliance: Understanding that failure to adhere to these responsibilities could result in the termination of the contract with the family, emphasizing the importance of strict compliance with the guidelines provided.
Team Training: Working with our Agency to train the DSP upon their first day working with the client
- Once support is found for the client listed above, we will train them on all the documents provided to us from you and the Service Coordinator.
- We ask for your support and willingness to complete 1-2 hours of hands-on training with the DSP on their first shift. We have found this yields the best results and maximizes the DSP's work effort and quality of care.
Back up Direct Support Professionals

A backup DSP can help provide continued support coverage during situations such as illness, emergencies, vacations, scheduling conflicts, or staff transitions. The backup DSP would also be trained on the client’s support plans and important care information so they can step in when needed and help reduce interruptions in services. This option is completely optional and can be discussed or added at any time after services begin.
Once we get services started and have a primary Direct Support Professional (DSP) assigned, would you like us to help identify a backup DSP if your regular DSP is unavailable? (Completely optional)
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Date

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Date
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Client Intake Form

Child

Person Centered Plan

Review of Services