St Louis Center Resident Application

St. Louis Center / St. Louis Guanella Village

Resident Application

16195 W. Old U.S. Hwy 12 Chelsea, MI 48118
Formfiller's Name*
Formfiller's Email*
example@example.com
Phone: (734) 475-8430*
Fax
Applicant Photo upload

Cancelof
Admission/Intake Requirements
In order for the treatment team to make a decision about placement into one of the programs, the following documents are needed for review:
- Application Form
- Behavior Checklist
- Current Educational Reports (for those still in school - IEP)
- Current Psychological Reports - This should be at least within three years of the time application is being made and must show a Full-Scale IQ score of 70 or below
- Medical Report - Example: seizures, medications(s), impairments, illnesses, hospitalization(s), etc.
- Social History: family members - siblings, home/living situation
- Agency I.P.O.S.
Once the intake packet is received and reviewed, a decision will be made on whether or not St. Louis Center/St. Louis Guanella Village can meet their needs. If so, an intake interview will then be scheduled, if not you will be provided with reasons why we cannot meet the applicant's needs at this time. During an intake interview, we will ask more in-depth questions about how we can care for the applicant. Financial obligations will be discussed with the financial department. An intake interview will take approximately one hour and will include a brief tour if you haven't already received one.

COVID-19 vaccination is required for residency.

State of Michigan Requirements - MUST be completed before placement date:
- Physical Examination with current immunization records (within 30 days of admission)
- Dental Examination (within 6 months of admission)
St. Louis Center/St. Louis Guanella Forms/Information that must be submitted one week prior to the admission date:
- Permission Forms (provided by St. Louis Center/St. Louis Guanella Village)
- Birth Certificate (Copy)
- S.S.I. Award Letter
- Proof of Guardianship
- Social Security Card (Copy)
- Agency contracts/approvals
We will hold a Person-Centered Plan Conference on the day of admission. During the meeting we identify strengths and weaknesses, specify treatment goals to improve overall functioning and maximize independence as well as identify indicators of goal achievement/regression, discuss Self-care Skills, Safety, Basic Communication Skills, Social Skills, Recreation, and Leisure Time Skills, etc. This meeting is held annually and reviewed quarterly.

New Resident Application
Date of Application*

MonthDayYear
Date
General Information

General Information about Applicant
Applicant's Last Name*
Applicant's First Name*
Applicant's Middle Name*
Birth Date*

MonthDayYear
Date
Birth City
Birth State
Social Security #*
Has applicant ever been on SSI, RSDI, SSDI, SSA?*

YesNo
Religion (if applicable)
Family Information

MOTHER:
Mother's Last Name*
Mother's First Name*
Mother's Middle Name*
Mother's Birth Date

MonthDayYear
Date
Mother's Address
Mother's Home Phone #
Mother's Work Phone #
Please enter a valid phone number.
Mother's Religion (if applicable)
Mother's Education
Mother's Occupation
Family Information

FATHER:
Father's Last Name*
Father's First Name*
Father's Middle Name*
Father's Birth Date

MonthDayYear
Date
Father's Address
Father's Home Phone #
Please enter a valid phone number.
Father's Work Phone #
Father's Religion (if applicable)
Father's Education
Father's Occupation

Family Information Continued...
New Resident Application Continued
Step Mother's Last Name
Step Mother's First Name
Step Mother's Middle Name
Step Father's Last Name
Step Father's First Name
Step Father's Middle Name
Parent's Marital Status:*

Never MarriedMarriedWidowedSeparatedDivorced
If widowed, indicate surviving parent:

First NameLast Name
Sibling #1: First Name Last Name Gender DOB Residence Occupation/School/Grade
Sibling #2: First Name Last Name Gender DOB Residence Occupation/School/Grade
Sibling #3: First Name Last Name Gender DOB Residence Occupation/School/Grade
Sibling #4: First Name Last Name Gender DOB Residence Occupation/School/Grade
Please list any other person(s) living in the home and their relationship to the applicant...
Legal Guardian Information
Legal Guardian's Last Name*
Legal Guardian's First Name*
Legal Guardian's Middle Name*
Complete the following if the Legal Guardian is NOT a Mother or Father
Legal Guardian's Birth Date

MonthDayYear
Date
Legal Guardian's City and State of Birth
Legal Guardian's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Legal Guardian's Home Phone #
Please enter a valid phone number.
Legal Guardian's Work Phone #
Please enter a valid phone number.
Legal Guardian's Religion (if applicable)
Legal Guardian's Education
Legal Guardian's Occupation

Reason for Application
What circumstances lead to making the decision to place the applicant at St. Louis Center/St. Louis Guanella Village?
What do you expect St. Louis Center/St. Louis Guanella Village to do for the applicant?
How long do you expect the applicant to live at St. Louis Center/St. Louis Guanella Village?
Have you applied for residential admission for this applicant at other facilities?

YesNo
Have you applied for residential admission for this applicant at other facilities?
Facility
Address
When?
Outcome?

New Resident Application Continued.
Behavior
Describe in detail any behavioral problems the applicant has (i.e. self abuse, aggression)
Describe any behavioral problems the applicant has at school or at a vocational program?
What procedures are most effective in dealing with the applicant?
What are the applicant's behavioral strengths?
How does he/she choose to spend his/her time?

New Resident Application Continued
Medical History & Information
List Current Diagnoses:
Date

MonthDayYear
Date
List Past Diagnoses:
Date

MonthDayYear
Date
Medication #1 Name of Medication #1 Frequency/Dose: Freq/Dose Med #1 Reason: Reason Med #1
Medication #2 Name of Medication #2 Frequency/Dose: Freq/Dose Med #2 Reason: Reason Med #2
Medication #3 Name of Medication #3 Frequency/Dose: Freq/Dose Med #3 Reason: Reason Med #3
Additional Medications and or Diagnoses File Upload

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Coordination Difficulties
Seizure Disorders - List type and Frequency
General Health at Present
Has the applicant ever been seen by a specialist (Neurologist, Psychologist, Psychiatrist, Other)?

YesNo
If yes, please list:
Specialist #1 Name
Title
Address
Results
Specialist #2 Name
Title
Address
Results

Comments
Relationship
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

	Independent	Tries with Assistance	Beginning with Assistance	Unable to Do	Not Functioning in this Area
Feeds Self
Drinks from cup
Drinks from glass
Drinks from straw
Drinks from fountain
Eats with spoon
Eats with fork
Cuts with knife

	Independent	Tries with Assistance	Beginning with Assistance	Unable to Do	Not Functioning in this Area
Dressing (clothing)
Footwear
Laces
Ties
Buttons
Shapes
Zippers
Identifies clothing according to weather

	Independent	Tries with Assistance	Beginning with Assistance	Unable to Do	Not Functioning in this Area
Washes hands when needed
Dries hands
Uses soap
Blows and wipes nose with tissues
Brushes teeth
Combs/picks hair
Washes & dries body
Washes & dries hair
Shaves
Applies deodorant
Bathing: Shower
Bathing: Bath
Personal Feminine Hygiene (if applicable)

	Yes	No	Sometimes	Never	Not Functioning in this Area
Wears diapers
Self-sufficient
Time-trained
Properly manipulates clothes before/after toileting
Bladder control: Daytime
Bladder control: Night time
Bowel control: Daytime
Bowel control: Night time
Properly uses toilet paper

	Yes	No	Sometimes	Never	Not Functioning in this Area
Identifies harmful/dangerous objects
Can cross a street safely
Reports injuries
Reports illness

Admission/Intake Requirements

New Resident Application

General Information

Family Information

Family Information

Family Information Continued...

Legal Guardian Information

Reason for Application

Behavior

Education Information

Medical History & Information

Behavior Check List

Behavior Check List

Behavior Check List

Behavior Check List

Comments

	Yes	No	Sometimes	Never	Not Functioning in this Area
Intelligent speech
Uses gestures with words
Intelligible when listener knows content
Easily understood by peers
Easily understood by familiar people
Easily understood by adults
Uses phrases
Participates in conversation
Can relate experiences in appropriate and meaningful order
Non-verbal
Uses sign language

	Yes	No	Sometimes	Never	Not Functioning in this Area
Listens carefully in most situations
Needs frequent direction in listening
Can follow one-step directions
Can follow two-step directions
Can follow multiple directions

	Yes	No	Sometimes	Never	Not Functioning in this Area
Can control temper
Has verbal outbursts
Has physical outbursts
Accepts changes in routine
Can accept losing in game situations
Can wait turn
Responds positively to authority
Respects criticism

	Yes	No	Sometimes	Never	Not Functioning in this Area
Uses "Please"
Uses "Thank you"
Uses other polite greetings
Can make simple introduction
Displays proper eating and table manners

	Yes	No	Sometimes	Never	Not Functioning in this Area
Good winner
Good loser
Participates enthusiastically
Participates readily
Participates when encouraged
Join group but does not participate actively
Behaves appropriately while shopping
Behaves appropriately while in van/car
Behaves appropriately during field trips
Participates as a member of family
Participates as a member of class
Participates as a member of church
Joins in activities at home
Is affectionate toward family members
Does what is requested by mother
Does what is requested by father
Does what is requested by siblings
Does what is requested by others

	Yes	No	Sometimes	Never	Not Functioning in this Area
Is enthusiastic and has fun in most work and social activities
Is truthful and honest
Is dependable
Complies with rules and regulations at school
Comoplies with rules and regulations at home
Knows own property
Respects the property of others
Displays some leadership in play
Shows and accepts affection
Appears to have positive self-concept
Appears to have poor self-concept
Is generally nervous unless accompanied by a familiar person
Is comprehensive about change in routines and environment
Refuses to participate unless completely successful
Temper tantrums: Physical (throwing/hitting objects)
Temper tantrums: Verbal
Temper tantrums: Abusive - self
Temper tantrums: Abusive - others
Joins in activities
Withdraws when angry
Becomes angry for no apparent reason

	Yes	No	Sometimes	Never	Not Functioning in this Area
Recognizes body parts
Recognizes changes during puberty
Exhibits some understanding of body changes during puberty
Exhibits some understanding of body changes during adolescence
Displays proper sexual behavior in public

	Yes	No	Sometimes	Never	Not Functioning in this Area
Runs skillfully in activities
Runs with physical assistance
Has ability to hop
Has ability to jump
Has ability to march
Has ability to use stairs with banister
Has ability to use stairs without banister
Has ability to catch a ball
Has ability to throw a ball

	Yes	No	Sometimes	Never	Not Functioning in this Area
Knows rights and lefts
Knows up and down
Recognizes body parts
Can coordinate eye-hand movements

	Yes	No	Sometimes	Never	Not Functioning in this Area
Initiates own play activities
Engages in parallel play
Plays cooperatively with peers
Plays contently alone, but likes to be near adults
Enjoys music
Enjoys T.V.
Enjoys singing
Enjoys coloring
Enjoys drawing
Enjoys painting
Enjoys swimming
Enjoys playing in water
Enjoys wading in water

	Yes	No	Sometimes	Never	Not Functioning in this Area
Clears dishes from table
Hangs up own clothes
Makes own bed
Prepare simple foods
Takes out trash/garbage