Member Referral Form

Applicant's Name *

Date of Birth *

Legal Sex *

Male

Female

Preferred Sex

Full Current Address *

Phone *

Social Security Number

Services Requested *

Hourly SCL

Daily SCL

Host Home

Tier Code *

U1

U2

U3

U4

U5

U6

Required

Primary Disability (Degree and Type) *

Other Diagnosis *

Ambulatory *

Yes'

No

Primary Language and Method of Communication *

Funding Source *

ID Waiver

BI Waiver

Private

Other:

Case Manager *

Case Manager's Phone, Email, Full Address *

Reason for Referral *

Expectations for Services

Please explain amount of supervision necessary and why. *

Are you ever left alone? *

Yes

No

How long are you left alone? *

Other Community Agencies Involved: Contact Person/ Address/ Phone *

Family Information (Mother, Father, Other Involved Family) Phone, Address, Email. (If Applicable) *

Do you receive financial assistance? *

Yes

No

If yes, give what type of assistance *

Yearly Amount *

Income other than financial assistance (Yearly Amount) *

Do you have a Payee? *

Yes

No

Other:

If yes, who is your payee? (Name, Phone Number, Address) *

Savings account *

Yes

No

Checking account *

Yes

No

Do you receive Medicaid Insurance? *

Yes

No

Insurance Policy Number or Member ID *

Do you receive Medicare Insurance? *

Yes

No

Insurance Policy Number or Member ID (Medicare) *

Other Health insurance Name and Policy Number

Do you have a funeral trust? *

Yes

No

If yes, with whom and amount of trust? *

Other Assets/ Resources? *

Guardianship? who is the guardian? If none put NA *

Guardian's Phone Number, Email, Address *

Date of Guardianship (Please Send Copy of Guardianship, and Funeral Trust Papers with this application) *

Do you have a will? *

Yes

No

A Trust? *

Yes

No

Do you have a power of attorney? *

Yes

No

Do you have a Burial Plan? *

Yes

No

Current Medications. Name, Dose, Frequency, Reason for Medication.( Can send in the medication sheet) *

Current PCP: Name, Phone Number, Address. Date of last exam. *

Current Dentist: Name, Phone Number, Address. Date of last exam. *

Current Psychiatrist: Name, Phone Number, Address. Last appointment. *

Other Specialist: Name, Phone Number, Address. Last appointment. *

Other Specialist: Name, Phone Number, Address. Last appointment.

Have you been hospitalized in the last 5 years? If yes, please explain. *

Have you ever received any mental health services? If yes, please explain. *

Do you have any physical disabilities that require the use of special devices? (Wheelchair, braces, walker, orthopedic shoes, splints, canes, etc.) Please explain. *

Are you allergic to medication *

Yes

No

Are you allergic to medication? Please Explain *

Are you allergic to food? Please Explain *

Are you allergic to anything else? Please Explain *

Are you on a special diet? Please Explain *

Do you have seizures? Please Explain the onset, last seizure date, and Frequency of Seizures. *

Are you able to communicate medical needs/concerns? Please explain: *

Illnesses Experienced

Chicken Pox

German Measles

Pneumonia

Measles

Polio

Croup

Mumps

Whooping Cough

Tuberculosis

Scarlet Fever

Rheumatic Fever

Hepatitis

Other:

Identified behavioral/mental health issues (Verbal and/or physical aggression, self-injurious behavior, elopement, etc. Include applicable information regarding frequency, severity, and target): *

Triggers of the behavioral/psychiatric symptoms: *

Cues given that behavior is about to occur (Statements, behaviors, sounds, actions, etc.): *

What should staff do in response? *

What should staff NOT do in response? *

This application was completed by: Name, Date, Phone, Relationship to Applicant: *