The Day D.E.N Program Application

The Day D.E.N Program Application

Please Fill Out Each Section and Upload Your Supporting Documents
Day D.E.N. Rules Document
Please review the Day D.E.N. rules before completing your application:
🔗 Click here to view the Day D.E.N. Rules
Upload Your Supporting Documents Here*

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Applicant Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Gender
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone*

Area CodePhone Number
Alternate Phone

Area CodePhone Number
Applicant E-Mail*
Marital Status
Name of Person Completing this Application
Relationship to Applicant
Phone Number of Person Completing Application*

Area CodePhone Number
Email of Person Completing Application*
example@example.com
Legal Representative

GuardianGuardian AdvocatePower of AttorneyRepresentative PayeeOther
Current Living Arrangment

Living in family household with parent/guardianLiving in Group HomeLiving in Assisted Living FacilityLiving independently in an apartment/house in the communityLiving with roommates in an apartment/house in the community
If currently living in a family home, group home or assisted living facility, has the applicant ever lived independently in the community?
If yes, how long?
How did you hear about ROAR Florida?*
Which of the following best describes your (the applicants) disability?*

AutismCerebral PalsyIntellectually Disabled (Diagnosis prior to age 18)Prader-WilliSpina BifidaDown SyndromeDevelopmental Disability as defined in 393.063(12), Florida StatutesOther
Support Services Disclaimer for Day D.E.N. Participants

ROAR Florida does not provide individualized support services for participants in the Day D.E.N. program. It is the responsibility of applicants, their legal representatives, and/or family members to ensure that any necessary supports are in place before participation. We recognize that some individuals may require assistance in specific areas in order to fully and safely engage in our programming. Therefore, as part of the application process, confirmation must be provided by the applicant and/or their legal representative that adequate support is already in place for program participation.
Does the applicant currently receive support services through the State of Florida?
Does the applicant receive service through Department of Vocational Rehabilitation (VR)?
If yes, please provide name and contact information below.
Support Service Information

Personal Supports/ In-Home SupportsSupported Living CoachingAdult Day TrainingBehavior AnalysisHome Health CareSupported EmploymentResidential Habilitation (group home)Companion ServicesTransportation Services
Support Coordinator Name

First NameLast Name
Support Coordinator Phone Number

Area CodePhone Number
Legal Representative or Primary Contact Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
What are the most important things we should know about the applicant in an emergency?*
Basic medical information
Does the applicant require the use of Epi-Pen or other emergency treatment for allergic reaction?
Is the applicant able to administer Epi-Pen independently?
If yes, please list allergies?
Does the applicant have a history of seizures?
If yes, what type?
How long do the seizures last?
Mins
When was applicant's last seizure?
How often does the applicant experience seizures?
Describe how the seizures are managed:
(VNS, Rescue Meds, Daily Meds)
Can the applicant self-administer seizure medication without assistance?
Does the applicant use any adaptive equipment?
If yes, please check all that apply:

Power WheelchairScooterCane/CrutchesHearing Aid(s)Manual WheelchairWalkerGlasses/ContactsShower ChairOther
Does the applicant use splints?
If yes, what type?
Does the applicant use a communication device?
If yes, what type?
Dietary Needs & Skills
Does the applicant eat meals and snacks independently?
Does the applicant require any special dietary requirements?
If yes, describe:
Are there any meal time safety concerns for the applicant (Choking, aspiration, stuffing mouth, ect.)
If yes, please describe:
Safety Skills
1. How long can applicant be left alone without supervision? (select the highest level of time possible)
2. Is the applicant able to sleep overnight without anyone checking on him/her?
3. Does the applicant know how to identify a stranger and know what to do if approached by a stranger?
4. Can the applicant safely navigate to familiar places in the community without supervision?
5. Is the applicant able to cross the street or walk through a parking lot safely without assistance?
6. Does the applicant know how to safely evacuate a building in the event of an emergency?
Transportation Skills
1. How does the applicant typically get around the community? Check all that apply:

Drives a carRides a bikeWalksTakes a busTakes a door-to-door bus service (i.e. Citrus Connection)Takes a car service (Uber/Lyft)Driven by a family member/friend
2. Is the applicant able to follow simple directions to get somewhere?
3. Can the applicant arrange their own transportation to get somewhere when needed?
Mental Health and Behavioral Supports
1. Does the applicant currently receive psychiatric care?
2. Has the applicant ever received psychiatric care in the past?
3. Does the applicant have any mental health diagnosis?
a. If yes, please check all current and past mental health diagnosis:

Bipolar DisorderDepressionObsessive Compulsive DisorderBorderline Personality DisorderSchizophreniaAnxiety DisorderADHD/ADDIntermittent Explosive DisorderOther
b. If yes, How will the applicant continue the management of the condition(s)?

Self-injurious Behavior

	Within past 12 months	Within past 3 years	Longer than 3 years ago	Never exhibited
Head banging
Biting/cutting self
Hair pulling
PICA (eating non-food objects)
Suicidal talk/threats
Suicide attempt
Other self harm behaviors

If other self harm behaviors, please describe:

Aggressive Behavior

	Within past 12 months	Within past 3 years	Longer than 3 years ago	Never exhibited
Hits/Kicks others
Bites others
Uses weapons against others
Threatens/bullies others
Stalks/harasses others

Inappropriate Sexual behavior

	Within past 12 months	Within past 3 years	Longer than 3 years	Never exhibited
Exposing self to others
Touching others without consent
Public masturbation
Sexual interaction with minors (physical, verbal or online)
Making inappropriate sexual comments
Sending unwanted sexual communications (i.e. texts, videos, pictures, calls, notes)

Destruction of Property

	Within past 12 months	Within past 3 years	Longer than 3 years	Never exhibited
Damages/breaks own possession
Damages/breaks others possessions
Damages/breaks furniture or decor
Breaks windows
Sets fires

Inappropriate Social Behavior

	Within past 12 months	Within past 3 years	Longer than 3 years	Never exhibited
Throwing tantrums (stomping feet, sitting on the floor, aggressive gestures, ect.)
Cursing in appropriate settings
Stealing from others
Repetitive vocalizations
Yelling at others

5. Has the applicant's behaviors resulted in medical treatment for self or others?
6. Please describe how the applicant expresses frustration or anger:
7. Does the applicant have a current behavior plan?
a. If yes, what behaviors are identified in the plan?
b. Who assists in monitoring the plan?
8. Has the applicant ever gone missing?
a. If yes, were the police involved?
b. Where did the applicant go?
9. Has the applicant ever been treated under the Baker Act or other involuntary mental health treatment?
If yes, please provide frequency, all date(s) and reasons for treatment:
10. Has the applicant ever been arrested?
If yes, please provide date(s) and explanation:
11. Has the applicant ever been convicted of a crime?
If yes, please provide date(s) and explanation:
12. Is the applicant a registered sex offender?
If yes, does the applicant have any restrictions?
Expectations
Please describe why you would like to participate in ROAR Day D.E.N:
Consent to Disclose Personal and Health Information & Applicant Acknowledgment

I, the undersigned applicant or legal representative, give ROAR Florida permission to collect, store, and disclose relevant personal and health information provided as part of the application and participation in the Day D.E.N. program. This includes, but is not limited to, medical history, diagnoses, medications, emergency contacts, and any other information necessary to support safety and informed program participation. I understand that this information will be kept confidential and stored in accordance with all applicable regulatory requirements and/or best practices. Information will only be shared with staff or professionals on a need-to-know basis to support the safety and well-being of the applicant. I understand that completion of this application does not guarantee acceptance into any of ROAR Florida's Day D.E.N. programs. I affirm that all information provided in this application is true and accurate to the best of my knowledge and that no relevant information has been knowingly omitted.
Signature of applicant
Date/Time
Signature of person assisting with this application

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The Day D.E.N Program Application

Support Services Disclaimer for Day D.E.N. Participants

Legal Representative or Primary Contact Information

Basic medical information

Dietary Needs & Skills

Safety Skills

Transportation Skills

Mental Health and Behavioral Supports

Expectations

Consent to Disclose Personal and Health Information & Applicant Acknowledgment