Anchor Healthcare Pediatric In-Home Care GAPP Intake Form

Anchor Healthcare Pediatric In-Home Care GAPP Intake Form

Please complete this form as fully as possible. The information helps Anchor Healthcare determine what documentation is needed for a Georgia Pediatric Program (GAPP) request. Completion of this form does not guarantee approval. GAPP services must be reviewed and approved through the required Medicaid/GAPP process before services begin.
Child Information
Child's Full Legal Name

First NameLast Name
Child's Date of Birth

MonthDayYear
Date
Medicaid ID Number
Gender

Other
Child's Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Primary Language Spoken at Home
School Name, if applicable
Does the child currently have an IEP?
Upload current IEP, if applicable

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Is the child in foster care or DFCS custody?
If yes, provide DFCS county, supervisor name, phone number, and email
Parent / Guardian Information
Primary Caregiver / Legal Guardian Name
Relationship to Child
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Guardian Address, if different from child

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Secondary Caregiver Name
Secondary Caregiver Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance and Medicaid
Primary Insurance

Other
Medicaid ID Number
Upload Medicaid Card

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Secondary Insurance, if applicable
Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Type of GAPP Request
What type of request is this?
What services are you requesting?
Requested hours, if known
Is the child currently receiving GAPP services?
If yes, list current provider, approved hours, and authorization end date
If transfer, upload transfer-related documents if available

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Diagnoses and Medical History
Primary Diagnosis
Secondary Diagnoses
Please check all conditions that apply

Other
Has the child been hospitalized in the last 12 months?
If yes, describe reason, dates, and hospital
Has the child had any ER visits in the last 12 months?
If yes, describe reason and dates
Primary Care Physician Name
Primary Care Physician Phone
Please enter a valid phone number.Format: (000) 000-0000.
Primary Care Physician Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
List all specialists involved in care
Upload physician office visit notes

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Upload hospital discharge summaries, if applicable

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Upload other medical records

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Medications, Allergies, Equipment
Current Medications
Does the child take any PRN or rescue medications?
If yes, list medication, when used, and how often
Allergies
Medical Equipment Used

Other
Describe equipment use and how often it is needed
Upload medication list, equipment orders, or DME documentation

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Skilled Nursing Screening
Does the child require any skilled nursing care?
Check all skilled needs that apply

Other
Describe the skilled nursing care needed
How often is skilled care needed?
What changes or emergencies require nurse intervention?
Functional Care Needs and Supervision Requirements
In your own words, what does your child need help with every day that another child the same age would not need?
Does the child require line-of-sight supervision while awake?
Does the child require supervision during sleep or overnight hours?
What happens if the child is left unsupervised?
Does the child recognize danger such as traffic, water, heat, sharp objects, stairs, strangers, or medications?
Does the child require physical assistance, not just reminders, to stay safe?
Describe any recent safety incidents, near misses, falls, injuries, choking episodes, wandering, elopement, or unsafe behaviors
How often does the caregiver need to stop other tasks to supervise, redirect, or physically assist the child?
What times of day require the most supervision or hands-on care?
Upload behavior plans, school notes, incident reports, safety plans, or caregiver logs, if available

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ADL Detailed Assessment

ADL Assessment Table

Rows	Level of help needed	How many times per day?	About how many minutes each time?	What hands-on help is needed?	What safety risk exists if help is not provided?
Bathing
Dressing
Grooming
Oral hygiene
Toileting
Diapering / incontinence care
Eating / feeding
Meal preparation for child
Transfers
Mobility / walking / wheelchair use
Repositioning
Skin care
Cleaning child’s personal care area
Laundry/linen changes related to child care

Incontinence
Is the child bladder incontinent?
Is the child bowel incontinent?
Does the child use diapers, pull-ups, briefs, or pads?
Number of changes during the day
Number of changes overnight
Does the child require help with hygiene, clothing changes, or linen changes?
Describe skin concerns, rashes, breakdown, or infection risk
Does the child require a toileting schedule, bowel program, catheter care, ostomy care, or other special toileting routine?
If yes, describe the routine, frequency, and hands-on help required
Does the child resist toileting, diaper changes, hygiene care, or clothing changes?
If yes, describe the behavior and how the caregiver must assist
Feeding Dependency
Can the child feed independently?

Other
Does the child have choking or aspiration risk?
Does the child require special positioning for meals/feedings?
Number of meals/feedings per day
Average time per meal/feeding
Describe feeding assistance needed
Special diet, texture modification, or fluid restrictions
Does the child have vomiting, reflux, poor intake, dehydration risk, weight concerns, or feeding intolerance?
If yes, describe symptoms, frequency, and what the caregiver must do
Does the child require formula mixing, pump setup, tube flushes, venting, tube site care, or medication through feeding tube?
If yes, describe each task and how often it is done
Upload feeding orders, swallow study, diet orders, or tube-feeding plan, if available

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Behavioral and Safety Concerns
Check all behaviors/safety concerns that apply

Other
Describe the safety concerns in detail
How often do these behaviors occur?
Which ADLs are affected by behavior or safety concerns?

Other
Does the child require hands-on redirection during ADLs?
Describe redirection or hands-on assistance needed
Has the child had injuries, near misses, police involvement, school incidents, or ER visits related to behavior/safety?
If yes, explain
Does the child have a behavior plan, ABA therapy, counseling, psychiatric care, school behavior intervention plan, or crisis plan?
If yes, describe services and upload plan if available
What specific caregiver actions are needed to prevent injury or unsafe behavior?
Sleep and Nighttime Care
Does the child wake during the night?
How many times per night on average?
Does the child wander or attempt to leave the room/home at night?
What care is needed overnight?

Other
Describe nighttime care needs and safety risks
Does the child remove diapers, clothing, braces, oxygen, feeding tubes, monitors, or other equipment at night?
Does the child have seizures, choking, vomiting, breathing concerns, wandering, or unsafe behavior at night?
How long is the caregiver awake assisting the child on a typical night?
How many nights per week does the caregiver's sleep get interrupted because of the child's care needs?
Mobility, Transfers, Positioning, and Equipment
Can the child walk independently?

Other
Does the child have fall risk, poor balance, weakness, contractures, paralysis, or unsafe climbing?
Does the child need help transferring between bed, chair, wheelchair, toilet, bath, car, or floor?
What level of help is needed for transfers?
Does the child need repositioning to prevent discomfort, pressure areas, contractures, respiratory issues, or skin breakdown?
How often is repositioning needed?
Does the child use wheelchair, walker, gait trainer, braces, hospital bed, Hoyer lift, bath chair, stander, stroller, or other equipment?

Other
Describe mobility, transfer, positioning, and equipment assistance needed
Upload equipment orders, therapy notes, mobility evaluations, or DME documentation, if available

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Therapy, School, and Community Function
What therapies does the child receive?

Other
Therapy frequency and provider names, if known
Does the child attend school, daycare, homebound instruction, or another program?

Other
Does the child have a school nurse, aide, paraprofessional, IEP, 504 plan, behavior plan, or health plan?
Describe school supports, limitations, missed school, early pickups, or safety concerns at school
Does the child need help during transportation, appointments, community outings, or transitions outside the home?
If yes, describe the assistance and safety concerns
Upload IEP, 504 plan, school health plan, therapy notes, or behavior plan, if available

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Caregiver Daily Schedule and Burden
Morning care routine and approximate time required
Afternoon care routine and approximate time required
Evening care routine and approximate time required
Overnight care routine and approximate time required
What are the hardest parts of caring for the child each day?
What support is needed most urgently?
Who provides the child's care now?
Is the primary caregiver working, unable to work, missing work, missing sleep, or physically unable to complete all care alone?
Are there other children, elderly relatives, or dependents in the home who also require care?
If yes, describe who else requires care and how this affects the caregiver's availability
What days and times are services being requested?
Explain why those specific hours are needed
What care tasks cannot safely be delayed or skipped?
Document Uploads
Upload Medicaid card

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Upload physician notes

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Upload medication list

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Upload hospital discharge summary

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Upload IEP, if applicable

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Upload seizure logs, if applicable

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Upload equipment/DME orders, if applicable

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Upload current nursing/PSS notes if renewal or transfer

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Upload other supporting documents

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Upload caregiver logs, daily care schedule, incident logs, behavior logs, feeding logs, seizure logs, or sleep logs

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Consents and Acknowledgements
Parent / Guardian Printed Name
Parent / Guardian Signature
Date

MonthDayYear
Date
Should be Empty:

Anchor Healthcare Pediatric In-Home Care GAPP Intake Form

Child Information

Parent / Guardian Information

Insurance and Medicaid

Type of GAPP Request

Diagnoses and Medical History

Medications, Allergies, Equipment

Skilled Nursing Screening

Functional Care Needs and Supervision Requirements

ADL Detailed Assessment

Incontinence

Feeding Dependency

Behavioral and Safety Concerns

Sleep and Nighttime Care

Mobility, Transfers, Positioning, and Equipment

Therapy, School, and Community Function

Caregiver Daily Schedule and Burden

Document Uploads

Consents and Acknowledgements