Let’s get started!April 26, 2024/in Uncategorized/by Katelyn2 Admission Application Step 1 of 3 33% General InformationDate: MM slash DD slash YYYY 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) MM slash DD slash YYYY 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:NC InnovationsLTCSState FundsDSSPrivate PayNo FundingIs 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. Add RemoveCommunication 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 No If yes, please list who:Medications:(Required)Does the member have any medications to be administered by staff during working hours? Yes No 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 No 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. Add RemoveInterest 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. Add RemoveFurther 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.Untitled First Choice Second Choice Third Choice UntitledUntitled First Choice Second Choice Third Choice Untitled https://reachforindependence.com/wp-content/uploads/2023/07/RFI_Logo.png 0 0 Katelyn2 https://reachforindependence.com/wp-content/uploads/2023/07/RFI_Logo.png Katelyn22024-04-26 13:24:422026-01-22 10:29:05Let’s get started!
