DTA: Onboarding Intake

ARIZONA DEPARTMENT OF ECONOMIC SECURITY

Division of Developmental Disabilities
PRE-SERVICE PROVIDER ORIENTATION
INSTRUCTIONS: This form is to be completed by the provider and the individual and/or responsible party receiving services prior to the initiation of services. A copy MUST be retained by the provider and a copy sent to the District Office. The provider must also ensure that a General Consent and Authorization form is completed and retained by the provider.
PROVIDER INFORMATION
Provider’s Name (Last, First, M.I)
Employer Tax No
AHCCCS ID No
YesNo
If Yes, Describe:
YesNo
YesNo
CRITICAL INFORMATION
Individual’s Name (Last, First, M.I.)
Assists No.
Birthdate

MonthDayYear
Date
Individual’s Address (No., Street)
City
State
ZIP Code
Guardian’s/Responsible Party’s Name (Last, First, M.I.)
Relationship
Phone Number
Format: (000) 000-0000.
Address (No., Street)
City
State
ZIP Code
Emergency Contact’s Name (If other than responsible party)
Relationship
Phone Number
Format: (000) 000-0000.
Support Coordinator’s Name
Office Location
Phone Number
Format: (000) 000-0000.
Name of ALTCS/DDD Health Plan
AHCCCS ID No.
Phone Number
Format: (000) 000-0000.
Primary Care Physician’s Name
Phone Number
Format: (000) 000-0000.
Address (No., Street)
City
State
ZIP Code
Urgent Care Facility’s Name
Phone Number
Format: (000) 000-0000.
Address (No., Street)
City
State
ZIP Code
Other Health Insurance Information
Day Program (If Applicable)
Name of Day Program
Program Type
Days and Hours of Attendance
Transportation Method
Day Program Address (No., Street)
City
State
ZIP Code
Phone Number
Format: (000) 000-0000.
HEALTH-MEDICAL
CURRENT MEDICATIONS AND SIGNIFICANT HISTORICAL ISSUES:
YesNo
Special Medication Instructions
ALLERGIES TO:
YesNo
Specify
YesNo
Specify
YesNo
Specify
YesNo
Specify
Recommended Response to Allergic Reaction
YesNo
Describe
Frequency
Approximate Duration
Recommended Response to Seizure Activity
ASSISTIVE DEVICES:
Vision
Hearing
Dental Appliances
PROTECTIVE DEVICES:
Instructions for Use
Purpose
Other Individualized Health Care Routines
PRE-SERVICE PROVIDER ORIENTATION
DIET:
FOOD
YesNo
YesNo
YesNo
YesNo
YesNo
NormalChoppedPureed
SPECIAL DIET
YesNo
Special Instructions
YesNo
Describe Eating Disorder
BEVERAGES
YesNo
YesNo
YesNo
YesNo
YesNo
Describe adaptive eating/drinking equipment
Describe if Special Liquid Intake Needs
System for Fluid Intake (If applicable)
COMMUNICATION
Uses complex sentencesUses simple sentencesSignsNods yes/noGestures
Describe Augmentative Communication Devices (If applicable)
MOBILITY
Excellent (not an issue)Moderate (e.g. stumbles)Poor (e.g. very unsteady, falls)
YesNo
Crawling/ScootingKneelingStandingWalkingRunningClimbing
N/AWalkerCaneCrutchesAFOsLeg BracesWheelchairRunningClimbingOther
Positioning Instructions
Lifting/Carrying Instructions
PERSONAL CARE SKILLS (Check all applicable items)

Personal Care Skills (Check all applicable items)

Rows	Dressing	Toileting	Bathing	Dental Care	Menses	Med Admin	Other
Independent
Requires Prompting/Reminding
Requires Limited Assistance
Requires Significant Assistance

IF APPLICABLE, DESCRIBE SPECIAL PERSONAL CARE NEEDS AND PREFERENCES
BEHAVIORAL CONCERNS (If applicable)
YesNo
Aggression

APPROXIMATE FREQUENCYRECOMMENDED INTERVENTION
Self-Injurious Behavior

APPROXIMATE FREQUENCYRECOMMENDED INTERVENTION
Property Destruction

APPROXIMATE FREQUENCYRECOMMENDED INTERVENTION
AWOL

APPROXIMATE FREQUENCYRECOMMENDED INTERVENTION
Self-Stimulation

APPROXIMATE FREQUENCYRECOMMENDED INTERVENTION
Sexual Acting Out

APPROXIMATE FREQUENCYRECOMMENDED INTERVENTION
Other Behaviors
Other

APPROXIMATE FREQUENCYRECOMMENDED INTERVENTION
YesNo
Reason for BTP
Method Used to Obtain Information (e.g., in person, case file)
SIGNATURES
Signature of Person Completing if Not Responsible Party
Relationship
Date

MonthDayYear
Print Provider’s Name
Provider Signature
Date

MonthDayYear
Print Responsible Person’s/Guardian’s Name
Responsible Person’s/Guardian’s Signature
Responsible Person's/Guardian's Signature
Date

MonthDayYear
Date
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. To request this document in alternative format or for further information about this policy, contact the Division of Developmental Disabilities ADA Coordinator at 602-542-0419; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request. Disponible en español en línea o en la oficina local.

Rows	Please Enter Start time to End time
Monday
Tuesday
Wednesday
Thursday
Friday

Rows	Please Enter time window for pick up and drop offs
Monday
Tuesday
Wednesday
Thursday
Friday

Embrace Life Transportation Policy

Please complete the following form if you wish to receive transportation from your provider.
I,Guardian Name, give permission to Embrace Life, Inc to transportMember Namein a authorized personal vehicle, company vehicle.
Scheduled transportation for pick up and drop off are important to follow as scheduled:

Scheduled transportation in the afternoon; picking up the member from school must be on time and we will wait up to 7 minutes prior to departing to the next scheduled transportation. In the afternoon, we will drop off at the end of the house driveway and wait for the member to enter the home. If nobody is home, we will wait up to 7 minutes prior to making an emergency call to the Program Supervisor to contact the guardian and/or emergency contact as listed.
Announcement/Newsletters

Embrace Life Services is working towards going paperless and we will need your email address to acheive this goal.

Please fill out the information below and check which communication methods you would like to receive news, announcements and/or documents. We will scan the program activity calendar, your members' Monthly Progress Report, Incident Reports, or any special monitoring report tool you wish. Thank you for helping us to go paperless!
Email Address:
Member Name:
Please mark here and we will continue to mail your information.
Statement of Understanding/ Responsbility

I understand the above written information and agree to adhere to all policies, procedures, and instrictions as they are written above and have been explained to me. I acknowledge that I will contact Administration if I have any questions.
Parent/Guardian Printed Name:
Parent/Guardian Signature:
Date

MonthDayYear
Date

Consents and Emergency Care
I,Full Name of the legally person responsible, certify that I am theRelationship to MemberofMember Full Name, who attends Embrace Life's Day Program.
TRANSPORTATION

I give permission to the Embrace Life, Inc provider to transport this individual on outings for respite and habilitation purposes.
Initials
MEDICATION ADMINISTRATION

I authorize the Embrace Life, Inc provider to administer prescribed medications as instructed by licensed doctor. I understand any provider from Embrace Life, Inc- must complete the medication training prior administer any medication.
Initials
EMERGENCY MEDICAL CARE

I gave my permission to provide basic first aid and medical treatment to this individual if necessary in case of an emergency.

I have read and understand the above statements. I may change my mind at any time. I agree to notify Embrace Life, Inc. If changes are needed to be made on this consent.
Printed Name
Signature of Individual or Responsible Party
Date

MonthDayYear
Date
Date*

MonthDayYear
Date
Full Name of the responsible person (print)
Full name of the responsible person (Signature)*

YOUR RIGHTS

You have the right to do what is best for yourself. If there is a concern about your rights, we will schedule a meeting with your Case Manager/Support Coordinator for further discussion on how to best support you. Below is an example of your rights but does not mean these are the only rights that you have.
Member Name*

First NameLast Name
You have the right to:

Express your feelings and opinions and the right to have help given to you to help you express your feelings and opinions. You can have someone you choose to help you make decisions. Remember: It is always okay to ask for help!

Always be treated fairly with dignity and respect.
Remember: No one should make fun of you in any way or make jokes that hurt your feelings. How others talk to you matter, so if someone hurts your feelings, make sure to tell someone that you trust!

Have all your personal information kept private.
Remember: No one should be talking about your personal information without your permission!

Have your own personal belongings.
Remember: If something belongs to you, then you have the right to keep those items where you chose to keep them. No one should be taking anything that belongs to you!

A clean, safe, and healthy home environment. Remember: You should have a clean, safe home like everybody else! You can ask for help to make sure your home is tidy.

Ask for help when working on goals to increase your skills.
Remember: You can ask for help at any point if you need any type of assistance while working on your goals.

Choose whether or not to participate in any activity.
Remember: Sometimes we have good days and sometimes we have not-so-good days and we need a break. It is okay to say no when staff asks if you would like to participate in an activity.

Have your own beliefs, language and culture respected. Remember: You should never be judged or picked on because of who you are or what you believe in.

You can change your provider or agency at any time.
Remember: If you are not happy with the services we are providing, you can request a meeting to discuss finding another agency or provider that best meets your needs.
Today Date:*

MonthDayYear
Date
Guardian Name:*

First NameLast Name
Signature*
Call 833-560-0333 to report any concerns anonymously!
I,   Full name of the legally responsible person   , give consent to the administration of:   Name of medication

For the prescribed purpose of:   Diagnosis of condition

Prescribed by:   Prescribing Licensed Physician

With a daily maximum dosage of,   Dosage in mg     for a time period not to exceed 12 months.

Media Release Permission
Please Read Carefully:

I am submitting information to Embrace Life Services for publication. As evidenced by my signature shown below, I give my permission for the attached article and/or photograph with my name and/or likeness (or the name and/or likeness of the person in my care) to be published in company publications* such as marketing brochures, newsletters, and online/social media. I understand that minor edits may occur or that it may not appear in its entirety to accommodate publication limitations.

*Company publiciations are distrubuted to individual and families served by the company, staff, advocates, service providers, and interested parties.
Do notDo
Text onlyPhoto onlyText and PhotoAudioVideo

PRN Sheet
Member Name*

First NameLast Name
This section is for parents or legal guardians to provide any PRN (as-needed) comments regarding medication or care. If you do not want to provide medication information, feel free to leave this box blank.
1. Acetaminophen Regular strength h      tablet/capsules take as directed on label as needed for pain or fever.
a. Do you have a preferred brand for the member to use?   Type a label

2. Ibuprofen 200 mg Type a label tablet/capsules as directed on label as needed for pain or fever.
b. Do you have a preferred brand for the member to use?   Type a label

3. Bismuth subsalicylate (Pepto-Bismol, Kaopectate, Maalox) use as directed on label for heartburn, upset stomach, diarrhea, indigestion.
c. Do you have a preferred brand for the member to use?   Type a label

4. Pseudoephedrine take as directed on the label as needed for nasal congestion, cough, cold and allergy.
d. Do you have a preferred brand for the member to use?   Type a label

5. Topical Analgesic (Caladryl lotion/anti-itch cream) - apply to skin as directed by the label.
e. Do you have a preferred brand for the member to use?   Type a label

Other::   Type a label

0ther:     Type a label
Today Date:*

MonthDayYear
Date
Legal Guardian Signature*

Please Enter your email to receive an copy.
example@example.com
Upon signing this form, you confirm that the questions above are answered to the best of your knowledge.
This PRN will be: Discontinue on the date of: 1 year from today date*

MonthDayYear
Date

Consent for Administration of Psychotropic Medications
I,Full Name of the legally person responsible, certify that I am theRelationship to MemberofMember Full Name, who attends Embrace Life's Day Program.
Date*

MonthDayYear
Date
Full Name of the responsible person (print)*
Full name of the responsible person (Signature)*

Release of Information
I,Full Name of the legally person responsible, certify that I am theRelationship to MemberofMember Full Name, who attends Embrace Life's Day Program.
The Organization/Provider/Person listed below may pick up and share communication for the member above to Embrace Life for a period of time not to exceed 12 months from the date listed below.
Name of Organization/Provider/Person
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date*

MonthDayYear
Date
Full Name of the responsible person (print)*
Full name of the responsible person (Signature)*
Should be Empty:

Rows	Medication name	Dosage	Frequency	Reason	Date Prescribed
Medication 1
Medication 2
Medication 3
Medication 4

PRE-SERVICE PROVIDER ORIENTATION

PROVIDER INFORMATION

CRITICAL INFORMATION

Day Program (If Applicable)

HEALTH-MEDICAL

ASSISTIVE DEVICES:

PROTECTIVE DEVICES:

PRE-SERVICE PROVIDER ORIENTATION

DIET:

FOOD

SPECIAL DIET

BEVERAGES

COMMUNICATION

MOBILITY

BEHAVIORAL CONCERNS (If applicable)

SIGNATURES

Embrace Life Services Intake Information

Schedule/Time

Medications

BEHAVIORS

Communication

Parent/Guardian Contact Information:

Embrace Life Transportation Policy

Consents and Emergency Care

YOUR RIGHTS

Media Release Permission

PRN Sheet

Consent for Administration of Psychotropic Medications

Release of Information