Membership Application
Application Date
*
-
Month
-
Day
Year
Date
Member's Name
*
First Name
Last Name
Chosen name if different from legal name
Member Pronouns
Gender
*
Please Select
Female
Male
Non-binary
Prefer not to answer
Member Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Birthday
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Living Situation
Home with family or caregiver
Independent
College Housing
Group Home
Assisted Living
Unhoused (shelter, car, transitional housing)
Treatment Center
Other
Primary Contact Name (if different from member)
First Name
Last Name
Primary Contact Email
*
example@example.com
Primary Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Contact Preferred Contact Method
Please Select
Phone
Email
Should Primary Contact be contacted for the following: Select all that apply
Medical or Behavioral Emergency
Billing
Activity Registration & Attendance
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Please describe your current living situation including name of housing and contact information for staff.
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Is the Member their own legal guardian
*
Please Select
Yes
No
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What is the legal guardian's name
Legal guardian relationship to member
Legal guardian phone
Please enter a valid phone number.
Format: (000) 000-0000.
Legal guardian email
example@example.com
Guardian Employer
Legal guardian address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Member Race (select all that Apply)
*
American Indian or Alaskan Native
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Asian
Hispanic, Latino or Spanish Origin
I do not wish to provide this
Member Ethnicity (Select all that apply)
*
Hispanic or Latino
Not Hispanic or Latino
I do not which to provide this
Other
Member Language of Care (what language do you use for appointments and/or activities)
*
Are interpreter services required?
*
If needed, do you have access to an interpreter?
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Does the member have any of the following services?
*
DVR (Department of Vocational Rehabilitation)
DDA (Developmental Disabilities Association)
WISe Team
Mental Health Provider
Life Skills Coach or other Coaching
Unsure
None
DDA Case manager (Name & Email)
DVR Case manager (Name & Email)
Member Primary Care Provider Name
Member Primary Care Provider Clinic Name
Member Diagnosis (select all that apply)
*
Autism Spectrum Disorder (ASD)
Cerebral Palsy
Developmental Disability
Tuberous Sclerosis
Hearing Loss
Vision Impairment
Developmental Delays
Down Syndrome
ADHD/ ADD
Traumatic Brain Injury
Genetic Disorder
Angelman's Syndrome
Learning Disability
Fetal Alcohol Syndrome
Other
Unknown
Other Psychological Diagnosis?
Other Medical Diagnosis?
Are you currently experiencing or have you experienced any of the following behaviors in the last 3 months?
*
Self harm
Aggressive tendencies
Elopement (leaving location)
None of these
Have you received 1:1 support for any of the following? (i.e. needs could not be supported by 4:1 staffing ratio)
*
Behavior Support
Medical Management
Safety
Self-Care (ie. toileting, eating)
None of these
Are you receiving services for any of these behaviors?
Yes
No
Do you have a 1:1 support person that will attend SCC w/you?
*
Yes
No
Can you leave SCC independently throughout your day?
*
Yes
No
We are a community of adults and participate in community outings and events. If at an event, can you partake in a glass of wine or beer? (if 21+)
*
Yes
No
Do you have any allergies? If so, what are they?
*
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Name of behavioral or mental health provider
*
First Name
Last Name
Provider email
*
example@example.com
Provider Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you willing to sign an ROI (release of information)?
Yes
No
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Services of Interest (select all that apply)
*
Unstructured hang out time
Recreation/ arts classes
Leadership
Skill building classes (ex. vocational skills, budgeting)
Community access (ex. outings, transportation training)
Cooking
Individualized Goals
Member's current goals:
*
What other activities are you engaged in?
Employment
School
Job coaching
Community groups (Alyssa Burnett Center, Tavon)
Recreation activities (Special Olympics, Seattle Parks and Rec)
ABA therapy
None of these
Other
How did you hear about us
*
In order to provide a safe and supportive environment for all, the SCC runs background checks on all members, staff, on-site care providers, and volunteers. This is a requirement of membership and involvement with the SCC. Do you agree to sign a background check form?
*
Yes
No
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