Online Application – Giving Hearts LLC

Name *

First

Last

Date / Time

Date

Time

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

DOB

SS#

Medicaid Number

Sex

Female
Male
Other

Race

Reason For The Referral

Referral Source

Reason For Referral

Explain

Support Coordinator's Name

Phone

Authorized Representative Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Ajudication

Date

Time

County of Ajudication

Diagnosis Axis I

Diagnosis Axis II

Diagnosis Axis III

Date of last Psychological

Date

Time

Measured IQ

Cause of Disability, if known

Current Residential Placement

Previous Day Placements

Reason For Termination

Single Line Text

Previous Day Placement

Reason For Termination

Type Explanation.

Skill Level (check all that apply)

Independent Living (Eating Skills)

Toileting skills

Never has Accidents
Occasional Accidents
Frequent Accidents
Wears Depends

Leisure Skills

Need Direction from Others
Self-Initiates

Interest

Type a description

Level of Supervision

Outdoors Unsupervised
Indoors Unsupervised
Continuous Supervision

Grooming Skills

Bathing
Dressing
Brushing Teeth

Vision

Normal
Wears Corrective Lenses
Legally Blind

Checkboxes

First Choice
Second Choice
Third Choice

History

Weight

Height

Medical Diagnoses

Food Allergies

Yes
No
Not Sure

Please Describe Below

Type in Allergic Foods

Reaction

Describe the reaction

Drug Allergies

Yes
No
Not Sure

Describe below

Name of Drug/Drugs Allergic to

Reaction

Seizures

Does The Client Suffer from Seizures?

Yes
No
Not Sure

Date of Last Seizure

Describe type of Seizure and Signs of Onset:

List All Medications and Indications - Include Does & Frequency (Prescribed and OTC)

Social Skills

Friendly
Like to be left alone
Likes to participate in groups

Receptive

Comprehends most spoken language
Comprehends limited spoken language
Responds to gestures/auditory cues
Responds to sign language
Does not respond to communicative stimuli

Behavior Concerns

Level of Behavior Concerns

1=Severe
2=Moderate
3=Mild
4=None

Academic Skills

Reads
Writes
Basic math skills
Budgeting skills

List Preferences

What Lead You To Seek Placement Today?

What needs of the applicant do you hope to have met through this placement?

What future goals does the applicant have?

Comments

Agency Representative

Date / Time

Date

Time

We desire to receive services from Independent Hands.

Yes
No
Maybe in the future

Individual

Date / Time

Date

Time

Authorized Representative

Date / Time

Date

Time

Support Coordinator

Date / Time

Date

Time

ONLINE REGISTRATION

Skill Level (check all that apply)

History

Seizures

Behavior Concerns

Notification