New Participant Application

New Participant Application
This form will be used for internal purposes by The Loveland Center administration to ensure we are able to safely support every individual in our care. Information provided on all Loveland Center intake forms must be truthful to the best of your ability.

Failure to disclose or purposeful misrepresentation may lead to perminant removale from Loveland programs and potential legal action.
Applicant Information
Name*

First NameLast Name
Preferred Name
Address*

Address

Street Address Line 2

CityState

Zip
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Gender*
Current Living Situation*

Family HomeGroup HomeSupported LivingAssisted Living FacilityIndependentOther
Resident Status*

Florida ResidentSeasonal
Emergency Contact
Contact Name*
Relationship*
Cell Phone*
Email*
example@example.com
Program Information
Select Your Program Location*

BradentonNorth PortPort CharlotteVenice
Select Your Program Type*

ResidentialDay ServicesAbility 1st ClinicSupport Services

Residential Settings you are interested in:

Supported LivingAssisted LivingGroup Home

Clinical Services You are Interested In:

Occupational TherapySpeech TherapyPhysical TherapyBehavioral SupportsCounseling

Support Services you are interested in

TransportationRecreationClubsSupported LivingPersonal Supports

Does the applicant have a legal guardian in the state of Florida?*

YesNo

Please attach a copy of the guardianship assignment for the State of Florida. Loveland CANNOT accept guardianship paperwork from another state. If Guardianship paperwork is not provided Loveland staff cannot release information to the person claiming guardianship without express permission from the participant
File Upload

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Guardian Name

First NameLast Name
Guardian Address
Guardian Email
example@example.com
Guardian Phone
Relationship to Applicant

Medical Information
Physician's Name*

First NameLast Name
Date of Last Physical*

MonthDayYear
Date
Physician's Address*

Address

Street Address Line 2

CityState

Zip
Physician's Phone Number*
Upload copy of latest Physical

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Date of Last Psychological Assessment or IEP*

MonthDayYear
Date
Upload Copy of Latest Psychological Assessment or IEP

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Primary Diagnosis*
Secondary Diagnosis
Height*
Weight*

List all medication details below or upload a list of medications

	Name of Medication	Dosage	Purpose	Side Effects
Med #1
Med #2
Med #3
Med #4

Upload Medication List if Applicable

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Do you have any allergies?

YesNo

Allergies
Signs/Symptoms and severity of allergic reactions

Does the individual have an active behavior plan?

YesNo
Has the individual had a behavior plan in the past?

YesNo
Behavior Analyst Name

First NameLast Name
Behavior Analyst Company
Behavior Analyst Phone Number
Please enter a valid phone number.
Please upload most recent behavior plan

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Describe any special assistance the applicant anticipates requesting
Funding Information
Please Select all that apply*

Pending MedWaive application rsponse from Florida's Agency for Persons with Disabilities (APD)On pre-enrollment for MedWaiver Funding from APDTuition will be funded by Medicaid WaiverTuition will be funded by Medicaid Waiver CDC+ ProgramTuition will be funded by Florida Community Care Pilot ProgramTuition will be funded by Private PayTuition will be funded by Longterm Care Insurance

Do you wish to apply for financial aide from Loveland Center?

YesNo

Waiver Support Coordinator or Case Manager Name

First NameLast Name
WSC or Case Manager Email
example@example.com
WSC or Case Manager Phone Number
Please enter a valid phone number.
WSC or Case Manager Company
Please Upload the most current version of your support plan created by your Waiver Support Coordinator

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Medicaid #

Basic Services
All of Loveland Center programs provide planned activities similar to those of non-disabled individuals that are designed to develop and maintain an individual's functional skills and include arrangements for utilization of available community resources. Individuals receive instruction in self-advocacy, community integration, self-care, and employment training both on campus and in natural environments. Individuals also receive care and supervision in the following areas:

*Selecting individual schedules and activities based on interests and abilities.
*Understanding the Rights of individuals with intellectual/developmental disabilities.
*Notifying family and other appropriate persons/agencies of the participant's needs.
*Determining goals from a variety of options.
Admission Criteria
1. An individual must have an Intellectual and/ or Developmental Disability.
2. Be at least 16 years of age for adult services and 4 years of age for children’s services.
3. Demonstrate a reasonable expectation of program participation.
4. All program participants must have a current written medical assessment performed by alicensed physician which is no more than one year-old. The assessment must include thefollowing information:
a. A record of any infectious or contagious diseases which would preclude care of theperson by program staff;
b. A test for tuberculosis;
c. Identification of the participant’s disability;
d. Identification of any prescribed medications being taken by the participant.

*Exceptions to the Admission Criteria will be considered on a case-by-case basis
By signing this form I agree to:

1) Cooperate with the general policies of the program that make it possible for the staff and participants to work together.

2) Not bring medications into the facility without the knowledge and pre-permission of the Program Manager.

3) Not be destructive of the property of the facility or other individuals.

4) Provide a minimum of two (2) weeks-notice when leaving the program unless the participant's physical/mental condition prevents it.

The signature of the Participant and/or Authorized Representative below indicates that all information provided in this application is truthful to the best of your ability and that the participant and/or their Authorized Representative has read or has had read to them this agreement and that this agreement has been explained in full to him/her, and that the signature below is signed voluntarily.

Additionally, you are committing to update this information throughout the year if any information should change.
APPLICANT SIGNATURE*
LEGAL GUARDIAN SIGNATURE
Date*

MonthDayYear
Date

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New Participant Application

Applicant Information

Emergency Contact

Program Information

Medical Information

Funding Information

Basic Services

Admission Criteria