Oklahoma MUHSEN Good Day Intake

MUHSEN Good Day Oklahoma Intake
Name of Participant

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current Age
Social Security Number (optional)
Are you willing to submit tuition payments within the first 5 business days of each month?

Other
If other, please explain
Emergency Contact Information
Emergency contacts (Guardian names, relationship to participant, and phone numbers)
Emergency contacts (siblings, grandparents, staff members, etc. Add relationship to participant and phone numbers)
Medical Information
Allergies
Medications
Medical Conditions to be Aware of (ex. seizures)
Are there any specific dietary restrictions or needs? (e.g., gluten-free, diabetic, halal, allergies)
Does the individual have any physical limitations or restrictions?
If yes, please provide details
Diagnosis / Disability
Medical Diagnosis (may bring in originals to copy)
Medical Diagnosis Date
Medical Diagnostic Evaluation

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Medical Insurance Card

Cancelof
Current Placement
Currently, participant attends (pick all that apply)
Name of the programs/schools. If other, explain
Current or most recent Individualized Education Plan (I.E.P.)

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Participant Individuality
Participant independent abilities are...be specific (ex. remembers to brush teeth in the morning, does the family laundry)
Participant will need help with...be specific (ex. transition timers)
Participant likes...be specific (ex. he loves Heinz mustard, she enjoys quiet instrumental music)
Participant does not like...be specific (ex. he does not like any music, she cries when she hears loud noises)
Participant Goals
WHAT IS A GOAL?

Here at the MUHSEN Good Day Program "Goals" have value and are very important. We believe in setting "SMART GOALS." Smart goals are Specific, Measurable, Achievable, Realistic and have a given Time Frame for accomplishment. A MUHSEN member's goal means he/she will work towards a specific effective goal (a desired result) with their determination and our help and guidance to achieve that (specific target) goal. Believing in our MUHSEN members, our process, performance and their outcomes is what gives MUHSEN member's goals value and importance.
PARTICIPANT goal #1: What are your specific goals?
PARTICIPANT goal #2: What are your specific goals?
Behavior History
Behavior Intervention Plan or Behavior Support Plan (most recent)

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Does the individual exhibit any of these behaviors? Check all that apply
If other, describe (please be specific):
Does the individual exhibit or have any aggressive behavior history?
Common aggressive behavior for the individual and the extent to which it occurs (be specific, an example is scratching and leaving a mark):
Does the individual harm themself during the aggression? Check all that apply:
If other, describe (be specific)
Will the individual harm others when they are escalated and aggressive?
What do aggressive behaviors towards others look like? Check all that apply:
If other, describe (be specific):
How frequent are the aggressions?
Elaborate on the above response (if it happens at certain times, when? specific triggers?):
Aggressions only happen when "this happens" (triggers, be specific):
How long can aggressive behaviors last, per aggression (be specific):
What is used or has been done to successfully calm aggressive behavior in school, at home, or in community settings (be specific):
Does your current approach at calming aggressive behaviors work?
Elaborate on the answer above, be specific:
Disruptive Behavior
Does the individual exhibit or have any disruptive behaviors? Check all that apply:
If other, please explain:
Does the individual engage in negative peer interaction? Check all that apply:
If other, please explain:
Does the individual engage in swearing/inappropriate words?
Does the individual engage in threatening statements towards themselves or others?
Does the individual refuse to follow instructions?:
Sexualized Behaviors
Does the individual engage in inappropriate self-touch (be specific):
Does the individual exhibit sexualized behavior in public (be specific):
Does the individual engage in content on their laptop or iPad that others find to be disruptive or offensive (be specific):
Does the individual engage in inappropriate sexual statements (be specific):
Elopement
Does the individual participate in elopement?
If the participant engages in elopement, what kind does it look like?
Elaborate on the above question (how frequent is elopement? what can trigger it? be specific):
What is used to subside/prevent elopement (be specific):
Behavior with Change
How does the individual react with change?
Elaborate on the answer above:
How does the individual adapt to change in routine?
How does the individual adapt to meeting new people?
Attention Span

How long is the individuals attention span (time in minutes?

Rows	>5 min	5 min	10 min	20 min	30 min	30+ min
Pays attention to work or craft
Can stay seated
Can stay standing
Can walk around

Self-Regulating Behavior
Self-Regulating Behavior (stimming) Check all that apply):
If other, explain:
Communication
What kind of communication does the individual use? Check all that apply:
If other, explain:
Does the individual have any specific words used, to help them understand?
If yes, often, or sometimes, please write down the words used:
Does the individual have any specific signs used, to help them understand?
If yes, often, or sometimes, please write down the signs used:
Personal Space
Does the individual have any problems with personal space of others?
Independent Living Skills
Does the individual require assistance with daily activities?
Any additional comments or statements you would like to share about a members form of communication? Everything is important and helpful to their success.
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MUHSEN Good Day Oklahoma Intake

Emergency Contact Information

Medical Information

Diagnosis / Disability

Current Placement

Participant Individuality

Participant Goals

Behavior History

Disruptive Behavior

Sexualized Behaviors

Elopement

Behavior with Change

Attention Span

Self-Regulating Behavior

Communication

Personal Space

Independent Living Skills