P.E.P. Center Intake Packet
Please complete this form in its ENTIRETY!  

If all fields are not filled out, we are not able to consider accepting your request to attend until these are filled out.  

This is so that we can fully understand what the needs of the individual are, and how we can best serve them in working toward their goals.
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Name of Individual wanting to attend *
Name of Person Filling out form (Also include your relation to the individual that will be attending, upon acceptance) *
Contact Phone Number *
Contact email *
Requested Start Date *
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Days Requesting to Attend (Check all that apply)          *3 days per week minimum Requirement* *
Required
Today's Date *
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Date of Birth *
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Current Age
Gender
Clear selection
Social Security Number (last 4 digits) *
State ID/Driver's License # *
Current Address (Street # and Name, City, State, Zip Code) *
Type of Residence
Clear selection
Staffing in Home
Clear selection
Current Supports Coordinating Agency *
Support Coordinator (Name and Phone #)
Current Managed Care Provider
Clear selection
Primary Diagnosis *
Secondary Diagnosis/Conditions
List Programs/Schools Attended by Individual for past 5 years *
List any Volunteer/Employment Placements within the last 2 years
Transportation Needs *PLEASE NOTE: this may or may not be available, SELECT ALL THAT APPLY! *
Required
Describe Individual's Physical Needs (toileting, feeding, lifting, etc.) *
Describe Individual's Behavioral Support Needs *
Required
List individual's triggers to becoming upset and needing assistance
Describe how we can best help the individual when they are upset ?
List any allergies and how the person reacts when exposed to those allergens:
Select any Health Risks we need to monitor for *
Required
Does the individual have seizures or take medication to control seizures?
Select all that apply and Describe individual's personal care ability (toileting, hand washing, sanitizing, general cleanliness/hygiene) *
Required
Select all that apply and Describe individual's verbal communication preferences and abilities
Select all that apply and describe individual's ability to understand directions *
Required
Select all of the Prompting / Assistance styles that work best   *
Required
List and describe ALL health conditions and Risks of Harm (i.e. eloping, fall risk, choking risk, skin breakdown risk, etc.) *
List all medications prescribed by a physician (include medication names and purpose below.  PLEASE NOTE: Physician's orders/prescriptions are required for all medications to be administered by P.E.P. staff. ******MUST NOTIFY PEP OF ANY CHANGES TO MEDICATION WITHIN 24-48 HOURS OF DOCTORS CONSULTATION***** *
Signature ( I hereby certify that I have answered these questions truthfully and to the best of my ability) TYPE OR PRINT NAME to agree *
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