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GEORGIA PEDIATRIC PROGRAM (GAPP) INTAKE QUESTIONNAIRE
Child's name*
First Name
Last Name
How did you hear about us?*
Why do you want help for your child? What do you need help with from our agency?*
What goals would you like for your child to accomplish?*
Client's Date of Birth*
-
Month
-
Day
Year
Date
Clients gender*
Client's Medicaid ID Number*
Does your child have private insurance?
Parent or Guardian's Name*
Parents email*
example@example.com
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Person's Name (This cannot be you.)*
Emergency Contact's Relationship to Child*
Emergency Phone Number*
Please enter a valid phone number.
Format: (000) 000-0000.
By selecting "YES", you agree to receive recurring messages from Quality Care InHome Care Services, Reply STOP to Opt-out. Reply HELP for help. Message frequency varies. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages.*
Client's Address*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is your child in DFCS custody?*
If "Yes" what is the name and address of the DFCS case manager?
Is your child currently receiving any other services from a Medicaid program?
If "Yes" please list the type of services your child is receiving.
Is your child in school?
How many DAYS PER WEEK does your child go to school?
How many HOURS PER DAY does your child go to school?
Does your child have a personal nurse at school?
Does your child have a CURRENT IEP? (Note: This IEP cannot be more than 1 year old. Please email a copy to info@qualitycareinhome.com after completing this questionnaire.)
Is there anyone else in your home who is currently in the GAPP Program?
If yes, please list their names below...
What is your child's medical diagnosis? (Please provide as many diagnoses as you can.)
How much does your child weigh?
What is the name of your child’s doctor?
Doctor's phone number?
Please enter a valid phone number.
Format: (000) 000-0000.
Doctor's Address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does your child have seizures?
If so... How often does your child have seizures and how long do the seizures last?*
Does your child have a G-Tube or feeding tube?
Can your child talk?
Is your child able to walk?
Does your child use a wheelchair?
Is your child on OXYGEN?
If so... How many hours per day is your child on OXYGEN?
Can your child use the bathroom without assistance?
Does your child wear diapers or pull ups?
Does your child have contractures? (A permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff. This prevents normal movement of a joint or other body part. Contractures may be caused by injury, scarring, and nerve damage, or by not using the muscles.)
Does your child receive any of the following services?
Occupational Therapy (OT)
Physical Therapy (PT)
Speech Therapy
Feeding Therapy
Does your child use any equipment?
Does your child take showers, regular baths, or bed baths?
Does your child have vision issues or wear glasses?
Is your child been prescribed to do any exercises?
Does your child wear AFO's? (Ankle-Foot Orthoses (AFOs) are lower limb orthoses that are custom made for each individual to encompass the foot, ankle and leg, just finishing below the knee).
Is there anything else you would like our nursing staff to know about your child? (Please be very specific. This can also include any likes, dislikes, etc.)
Which type of feeding does your child use?
Does your child have swallowing issues?
Does your child have any allergies?
What Medications Does Your Child Take?
BATHING
PERSONAL CARE
AMBULATION (WALKING ASSISTANCE)
COMPANIONSHIP
TOILETING
HOUSEKEEPING
NUTRITIONAL SERVICES
MEDICATION SERVICES
SKILLED NURSING SERVICES
TRANSFERRING
FEEDING
DIET (WHAT TYPE OF DIET IS YOUR CHILD ON?)
Do you consent for Quality Care Inhome Care Services to communicate with you by text message? This can include things such as nursing appointment confirmations, schedule changes, and emergency notifications.
Picture (Please upload a photo of your child. Please note that this image will not be shared with anyone outside of QCIHCS and is strictly used for recordkeeping purposes.)
Picture (Please upload a photo of your child. Please note that this image will not be shared with anyone outside of QCIHCS and is strictly used for recordkeeping purposes.)
*
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