GUIDED STEPS NY - INTAKE FORM

Guided Steps NY, Corp "GSNY" INTAKE APPLICATION
Client Information
First Name
Last Name
Medicaid CIN
Date of Birth

MonthDayYear
Traumatic Brain Injury (TBI)
Nursing Home Diversion Wavier NHTD
Approved/Suggested Units
Services Please Check

Individual Skills Training
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Emergency Contact Information (If applicable)
Phone (home)
Phone (cell)
Fax
Email
example@example.com
Marital Status
Protective Safeguards

BEHAVIORS (if applicable)
Toileting needs
Type of assistance needed
Mobility Assistance Needed

YesNo
Dizziness / Loss of Balance

YesNo
Fall in the last 3 months

YesNo
Wanders

YesNo
Mobility Devices
Dietary / Special Needs
Aggression and / or Combativeness
Verbal Inappropriateness
Behavior Plan
CLIENT ATTRIBUTES (Please Check) (If applicable)

CatsGogsNon-SmokerClient needs non-smoking caregiverSmokerMonitor Ambulation
Notes:
Service Coordinator Contact Information
Type Name

First NameLast Name
Email Address
example@example.com
Date

MonthDayYear
Date
Should be Empty:

Client Information