Individual Intake Form
Service Location(s):
Park West Court Apartments (PWCA)
Johnstown (JT)
Supported Community Living (SCL)
Career, Activity, & Community (CAC)
Non-medical Transportation (NMT)
Open Door Art Studio & Gallery (ODAS)
Open Door Stage & Screen (ODSS)
UCO
UCO NMT
Funding Source: (ICF, Respite, Hospice, I/O Waiver, Private pay, etc..)
Projected Start Date:
-
Month
-
Day
Year
Date
Admission Date:
-
Month
-
Day
Year
Date
Admission Time:
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
05
10
15
20
25
30
35
40
45
50
55
Minutes
AM
PM
AM/PM Option
Admission Date/Time is:
Anticipated
Actual
Individual's Information
Individual Name:
First Name
Last Name
What name should be used for this person?
What pronouns should be used for this person?
She/her/hers
He/his/him
They/them/theirs
Other
What is this person's gender identity?
Female
Male
Transgender male
Transgender female
Nonbinary or genderqueer
I don't know
Chose not to disclose
Other
What sex was this person assigned at birth on their original birth certificate?
Female
Male
Current place of residence:
*
Why does the individual want to move out of current living situation?
*
Address where individual will be living:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this the address where commission checks should be sent?
Yes
No
Address where commission checks should be sent:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Which PWCA Apartment will individual be residing in?
*
A1
A2
A3
B1
B2
B3
C2
C3
Does the individual have personal belongings to bring during admission?
*
Yes
No
Additional comments regarding personal belongings:
In which county will services be provided?
Does the individual have a pet?
Yes
No
List pet(s):
Individual's current phone number:
-
Area Code
Phone Number
Individual's email address:
example@example.com
Date of Birth:
-
Month
-
Day
Year
Date
Place of Birth:
*
Social Security Number (SSN):
xxx-xx-xxxx
Medicaid Number:
Medicare Number:
Level of Intellectual Disability:
Mild
Moderate
Severe
Profound
Acuity Assessment Score:
A
B
C
Funding Source:
I/O Waiver
Level One Waiver
County Funded
Private Pay
OOD
Individual Employment Supports
Other
Start Up Required:
Yes
No
Waiver Span Begin Date:
-
Month
-
Day
Year
Date
Waiver Span End Date:
-
Month
-
Day
Year
Date
Billing:
Adult Day Services
Vocational Habilitation
Other Benefits:
VA
OPERS
Trust
Other
Is the individual their own guardian?
Yes
No
Guardian Information
Guardian Name:
First Name
Last Name
Guardian Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Guardian Phone Number:
-
Area Code
Phone Number
Guardian Email Address:
example@example.com
Important Contacts
Current Residential Provider Name:
Residential Provider Phone Number:
-
Area Code
Phone Number
Residential Provider Email Address:
example@example.com
Service Coordinator/Placement Liason Name:
*
First Name
Last Name
Service Coordinator/Placement Liason Email Address:
*
example@example.com
Service Coordinator/Placement Liason Phone Number:
*
Does the individual have family or friends who should be listed as contacts?
*
Yes
No
How many contacts does the individual have?
1
2
3
Contact 1 Name:
First Name
Last Name
Relationship to Individual:
ex. Sister
Contact 1 Phone Number:
Contact 1 Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact 1 Email Address:
example@example.com
Contact 2 Name:
First Name
Last Name
Relationship to Individual:
ex. Sister
Contact 2 Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact 2 Phone Number:
Contact 2 Email Address:
example@example.com
Contact 3 Name:
First Name
Last Name
Relationship to Individual:
ex. Sister
Contact 3 Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact 3 Phone Number:
Contact 3 Email Address:
example@example.com
History
If the individual works or goes to school, please provide details:
Family history:
*
Health, Safety, & Supports
Does the individual have any health and safety risks? If so, please describe:
Does the individual smoke?
Yes
No
Is the individual able to smoke independently?
Yes
No
Additional smoking supports needed (check all that apply):
Smoking apron
Smoking device
Does the individual have a behavior plan in place?
*
Yes
No
Are there behavior guidelines in place?
*
Yes
No
Does the individual qualify for a behavior add-on?
Yes
No
Does the individual have alone time at home?
*
Yes
No
Does the individual have alone time in the community?
*
Yes
No
Do any of these apply to the individual?
Fall risk
Side rails up (for safety or for ADL's)
Bed alarm
Chair alarm
Low bed
Wheelchair
Seatbelt use (select all that apply):
Front
Rear
For medical or behavioral reasons (select all that apply):
Wander Guard
Body pillows
Is there additional medical training that needs to be provided?
Yes
No
List any medical training needs:
Does the individual have mobility needs?
Yes
No
Specific Mobility Needs (select all that apply):
Wheelchair
Walker
Power Chair
Other
Individual transfers:
*
Independently
Staff transfers
Supervision
Additional supports needed for transfers (check all that apply):
1-2 people
Pivot
Cane
Walker
Mechanical (Hoyer)
Rails
Other
Additional comments regarding transfers:
Communication skills:
*
Clear
Slurred
Non-Verbal
Sign Language
Does the individual use a communication device?
*
Yes
No
Is the individual able to use the communication device independently?
Yes
No
Additional comments regarding communication:
Proposed Schedule of Services
Please enter proposed schedule in table below:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
SCL
(List Hours)
CAC
1st Shift
CAC
2nd Shift
ODAS
NMT
UCO
UCO
NMT
Staffing Preferences
Does the individual have any staffing preferences (select all that apply)?
Male
Female
Non-Smoking
Sign Language
CCHS Representative Information
Form Completed By:
First Name
Last Name
Email
example@example.com
CCHS Representative Signature:
Submit
Should be Empty: