Application for Services Form

Date of Application:

Name of Applicant:

Last Name *

First Name *

Middle Name

Present Address:

Street Address *

City

State

ZIP

Phone Number:

Home *

Other

Date of Birth *

Social Security Number

Marital Status (Please Check)

Single	Married
Divorced	Widowed

Primary Language (Please Check)

English

Spanish

Other

Other; Specify:

Communication Mode (Please Check)

Verbal

Gestures

Vocalizations

Sign Language

Device(s)

Device(s) (Specify)

Name of Contact, if other than applicant:

Last Name

First Name

Relationship to Applicant

Phone Number:

Home

Other

Days requesting attendance (Please circle all that applies)

M

T

W

Th

F

Time Requesting Attendance:

Start Time:

End Time:

Transportation to and from Day Care: (Please Check)

Personal

Metrolift

Program Transport

Participating Meals (Please Check all that applies)

Breakfast

A.M. Snack

Lunch

P.M. Snack

Dinner

Place of Birth:

City

County

State

US Citizenship (Please Check)

Yes

No

Ethnicity

Religion

Legal Status (Please Check)

Competent

Incapacitated (Court Appointed Guard)

Medicaid (Please Check):

Y, Number (#)
N, Have applied and been denied
NM, Have never applied

Other Sources (Please Check):

United Healthcare

Amerigroup

Molinia

Other

(If checked) Please provide Information:

Policy Number (#)

Group Number

(Please provide a copy of Insurance Card checked above)

Estimated Annual Income of Applicant:

Primary source of Income: (Please check)

SSI

Wages

Other

Other means of financial support

Name of Emergency Contact

Relationship to Applicant

Address

City

State

Zip

Phone Number:

Home

Other

Mobility (Please check one)

Walks Independently	Walks with assistance from others
Uses wheelchair Independently	Uses wheelchair with assistance from others

Describe / List any adaptive equipment used for mobility:

Describe assistance needed to get from one place to another:

Eats Meal Independently:
Yes
No (No, Please describe help needed:)

Bath Independently:
Yes
No (No, Please describe help needed:)

Dresses Independently:
Yes
No (No, Please describe help needed:)

Rest Room Independently:
Yes
No (No, Please describe help needed:)

Describe any other assistance needed/comments:

Describe how applicant interacts with others:

Describe things that the applicant like or that motivate him/her:

Describe applicant's ability to make choice:

Describe any significant behaviors:

Known allergies (Food, Medication, Other):

Existing Medical Conditions/Diagnoses:

Applicant Full Name

Guardian Full Name

Witness Full Name

Date: