Uncategorized Archives | Reach For Independence

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General Information

Date:

Member Name:(Required)

First Last

Current Address:

Street Address City State / Province / Region ZIP / Postal Code

Phone Number:

Email:

LME/MCO Record Number (if applicable):

Date of Birth:(Required)

Gender:

Male

Female

Medicaid Number:

Guardian Name:(Required)

Guardian Contact Information (if different than above):(Required)

Current Living Situation:

Is the member currently residing at home, in a facility, AFL, or homeless?

Requested Services:(Required)

Day Program

Residential (AFL)

Community Networking

CLS

Supported Employment

Respite

LTCS

1915i

Other

Current Funding Source:

Is there a Care Manager Involved?:(Required)

If so, list name and contact information below.

Medical Information:

List Diagnoses:(Required)

Use the (+) button to add as many boxes as necessary.

Communication Skills:(Required)

Verbal

Non-verbal

Uses assistive technology

Sign language

Describe how we can best communicate with the member:

Is the member under the care of a primary care physician?(Required)

Yes

If yes, please list who:

Medications:(Required)

Does the member have any medications to be administered by staff during working hours?

Yes

If yes, please list all medications to be administered by staff:

Medical Conditions:(Required)

Does the member experience any of the following? If the member has more than one medical condition, please select "Other" and specify in the comments.

Seizures

Allergies

Heart conditions

Vision impairments

Hearing impairments

Breathing difficulties

N/A

Other:

If yes, please describe:

Mobility:(Required)

How does the member ambulate?

Ambulatory/no assistance needed

Ambulatory/light physical assistance needed

Non-ambulatory, uses wheelchair full time

Requires other equipment (walker, braces, occasional wheelchair)

Other

Please describe:

Eating:(Required)

Are there any special requirements for the member to eat safely?

Eats safely by themselves

Needs prompting while eating

Requires pureed food

Uses a feeding tube

Choking hazard

Please describe:

Personal Care Needs:(Required)

Check all that apply and use the comment box to go into detail.

Needs full assistance toileting

Can toilet independently

Needs prompting/reminders for toileting

Uses adult underwear

Bathes independently

Needs full assistance bathing

Needs prompting/reminders for bathing

Other

Please describe:

Does the member currently experience, or have a history of experiencing any of the following?(Required)

If more than one of the following choices apply to the member, select "Other" and specify in the comments.

Aggressive behavior

Self-injurious behavior

Elopement

Physical outbursts

Verbal outbursts

Property destruction

N/A

Other:

If yes, please explain: (If past behavior, when did the last incident occur?)

Does the member have a criminal record, or history with the police?(Required)

Yes

If yes, please explain:

Further Information:

Education:

What is the member's highest level of education? Please describe the member's limitations and/or skill level in reading, writing, counting, etc.

Interest and Skills:

Tell us about the members current interests, hobbies, skills, employment history (if applicable), likes/dislikes, goals that Reach for Independence can assist with.

Further Comments:

Is there anything else you would like to tell us about the member and how we can best support them?

Upload Documents:

If applicable, upload the members current Care plan, Psychological evaluation, and any other documentation that can aid us in our decision to best support the individual.

Accepted file types: pdf, doc, docx, Max. file size: 25 MB.

Terms and Conditions(Required)

I agree that the information being submitted is true and accurate from the best of my knowledge. I understand that Reach for Independence, Inc. will review the information submitted and will determine eligibility based strictly on the Agency's ability to best support the member and/or staff availability.

I agree to the terms and conditions.

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