GUIDED STEPS NY - INTAKE FORM

Guided Steps NY, Corp "GSNY" INTAKE APPLICATION
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:
Please attach any additional information ( if needed)
Completed By

Clear
Date

MonthDayYear
Date
Should be Empty:

Protective Safeguards