Application for Day Habilitation Services

Clear Head Westbank Day Habilitation Application
Welcome! Please fill out this application. Our staff will review it and follow up with next steps or any additional documents needed.
Participant Information
Participant Full Name

First NameLast Name
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medicaid Number
Primary Diagnosis or Disability
Parent/Guardian Information
Parent or Guardian Full Name

First NameLast Name
Relationship to Participant
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Medical and Support Needs
Current Medications
Allergies or Medical Concerns
Dietary Restrictions
Is medication administration needed during program hours?
Special Accommodations or Support Needs
Program Information
Requested Start Date

MonthDayYear
Date
Days Interested in Attending
Is transportation needed?
Pickup Address (if transportation is needed)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Waiver/Case Manager Information
Support Coordinator Name
Agency
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address (optional)
example@example.com
Safety and Behavior Support
Are there any behavior supports or safety concerns staff should know before the first day?
Document Uploads
Upload Medicaid Card

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Upload State ID

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Upload Guardianship Paperwork (if applicable)

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Upload Behavior Support Plan

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Upload Seizure Protocol (if applicable)

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Emergency Contact
Emergency Contact Name

First NameLast Name
Relationship to Participant
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Consents
I consent to emergency medical treatment if needed
I acknowledge transportation is needed if requested
I confirm all information provided is accurate
Signature
Parent or Guardian Signature
Date

MonthDayYear
Date
Thank you for completing the application. We appreciate your time and will be in touch soon.

Clear Head Westbank Day Habilitation Application

Participant Information

Parent/Guardian Information

Medical and Support Needs

Program Information

Waiver/Case Manager Information

Safety and Behavior Support

Document Uploads

Emergency Contact

Consents

Signature