ELIM CHRISTIAN SERVICES ADULT SERVICES SOCIAL HISORTY FORM

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Hubert Jefferson
5 years ago
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1 A. IDENTIFYING INFORMATION: ELIM CHRISTIAN SERVICES ADULT SERVICES SOCIAL HISORTY FORM 1. Name of Applicant: Birthdate: Birthplace: City State County Sex: Race: 2. How long has the applicant lived in Illinois? List names of cities and states of residence: B. INFORMATION ABOUT APPLICANT'S FAMILY: 1. Father's Name: Contact: Street: City/State/Zip Code: Home Phone: Cell Phone: address: 2. Mother's name: Contact: Street: City/State/Zip Code: Home Phone: Cell Phone: address: 3. Applicant's brothers and sisters (include half and step brothers and sisters): Sibling Names Birth Date

2 C. APPLICANT S PERSONAL HISTORY: 1. Check all of the following which describes the applicant: Alert Generous Loud Selfish Angry Happy Mean Sensitive Caring Helpful Moody Shy Destructive Hyperactive Obedient Slow learner Disrespectful Impulsive Peaceful Smart Easily Distracted In Own World Personal Space Tearful Energetic Indifferent Quiet Threatening Fearful Intimidating Reflective Withdrawn Forceful Kind Respectful Other: Friendly Lazy Responsive Other: 2. How does the applicant get along with each member of family and describe: 3 Who does the applicant engage with regularly: parents, siblings, extended family, neighbors, community, church, school, service agency, peers, friends? 4. What was the last school the applicant attended? Check one: Diploma Certificate 5. Work History (include workshop attendance) Company: Job Description/Duties: Job Title: Independent Wages: Minimum Wage Subminimum Wage Volunteer Supervised Street Address: Phone: ( ) City: State: Zip Code 2

3 Company: Job Description/Duties: Job Title: Independent Wages: Minimum Wage Subminimum Wage Volunteer Supervised Street Address: Phone: ( ) City: State: Zip Code Company: Job Description/Duties: Job Title: Independent Wages: Minimum Wage Subminimum Wage Volunteer Supervised Street Address: Phone: ( ) City: State: Zip Code 6. List all therapies applicant has received? 7. Was applicant ever arrested? Yes No If yes, give details: Are any charges pending? Yes No N/A COMMENTS: Name of person completing application: Relationship to applicant: Date Completed: 3

4 ELIM ADULT SERVICES HEALTH AND MEDICATION HISTORY Name: Date of Birth: (Last) (First) Parent/Guardian: HEALTH HISTORY: At what age was the applicant diagnosed as having a disability? What was the diagnosis? Check all that the applicant has had: Chicken pox [Year] Ear infections [Year] High fevers [Year] Convulsions [Year] Heart disease [Year] Kidney problems [Year] Other: HOSPITALIZATIONS Reason for Hospitalization Applicant's Age Preferred Hospital: Address: Primary Care Physician: Physician s Address: _ Physician s Phone Number: Current Medications HEALTH STATUS: List all allergies to medicine, food, etc. Diet Restrictions: Page 3

5 Eating/Feeding Issues? Please explain: Hearing: Vision: Most Recent Test Dates Last physical: Neurological evaluation: Results: If the applicant has seizures, please describe how frequently and how he/she acts when having a seizure: NECESSARY EQUIPMENT: Prothesis (crutch, cane) Helmet Hearing aid Wheelchair Brace Special shoes Glasses Other: What medications is the applicant currently taking? Name of any medical specialists (Name) (Name) (Speciality) (Speciality) Additional information: (Signature) (Date) G:\KFEIL\WORD\FORMS - - MISC.\HEALTH AND MEDICATION HISTORY Page 4

6 1. PERSONAL CONTACT INFORMATION ELIM CHRISTIAN SERVICES ADULT SERVICES INQUIRY FORM Name of Applicant: Sex: Female Male Birth Date: Current Residence: Home Residential Placement If applicable, name and address of Residential Agency: Name of current School or Day Program: Month & year of high school graduation: If attending Elim, name of program: Religious Affiliation: Reformed Protestant Catholic Orthodox Non-denominational Jewish Muslim Other None Parent/Guardian Names: Contact: Street: City/State/Zip Code: Home Phone: Cell Phone/Name: *Please include area codes & contact name. address: : Guardian(s) Is the applicant his or her own guardian? Yes No If no, name(s) of guardian(s) & relationship: 2. FUNDING Does the applicant receive state funding? Yes No If no, is the applicant on PUNS? Yes No Are you interested in private pay? Yes No PAS Agency/ISC Name: HBS Agency/Service Facilitator Name: 3. MEDICAL INFORMATION Primary Disability: PAGE 1

7 Secondary Disabilities: Cognitive Level: Mild Moderate Severe Profound Medical Issues: Does the applicant need to take medication during service hours? Yes No Does the applicant require nursing service during service hours? Yes No Allergies: Medication Food Seasonal Environmental Specify Allergies: Diet Restrictions: Assistive and Communication Devices: 4. FUNCTIONAL ABILITIES A. Gross/Fine Motor Mobility (check all that apply): independent physical guidance crutches walker wheelchair manual power Comments: Use of both hands: functional limited function no function Comments: B. Daily Living Skills Check if Daily Living Skill help is required Toileting Describe/Explain Assistance Required Dressing Grooming Eating C. Communication Primary Language English Spanish Other specify PAGE 2

8 Check all that apply: verbal communication device sign language photo/pictures facial expression/gestures/body movement Comments: D. Vocational Has the applicant ever worked: Yes No Where? Describe Work Tasks and Job Tasks Performed: _ E. Behavior Check all that apply Injures self Behavior Causes pain/harm to others Breaks/damages property Interferes with others or activities Unusual/repetitive habits Offensive behavior Withdrawn/inattentive Uncooperative/stubborn Other: Describe/Explain Behavior Does the applicant have a behavior program: Yes No Does the applicant take medications for behavior/mood: Yes No Comments: 5. INTERESTS What does the applicant enjoy doing at home during his or her free time? Where does the applicant enjoy going in the community? What are the applicant s special interests and passions? PAGE 3

9 6. ADDITIONAL INSIGHTS 6. SERVICES DESIRED Service Desired Program ACTS/Autism (staff ration 5 to 1) Mild (DT 3 Orland-staff ration 10 to 1) Moderate (DT 3-staff ration 8 to 1) Severe/Profound (DT 1/Day Service-staff ratio 5 to 1) Aging Disorders (Seniors-staff ration 5 to 1) Comments 7. TRANSPORTATION Elim offers several transportation options. Families are invited to choose the option that best fits their applicant s needs and family budget. Check your preference. Premier Door-to-Door van service (at an additional cost to me) A pick up/drop off point (at no additional cost to me) PACE vouchers Providing my own transportation Name of person completing application: Relationship to applicant: Date Completed: Send application and any available related materials to: Priority: Initials: Elim Christian Services Received: Follow Up: Donna Terry S. 70 th Court Tour: Entered on Database/Filed: (708) ext. 605 PAGE 4

Name: Last First Middle. Date of Birth: / / Place of Birth: Current Address: Street City State Zip # of years

Name: Last First Middle. Date of Birth: / / Place of Birth: Current Address: Street City State Zip # of years The Arc Baltimore Application for Services (Please Print or Type) of Application: Check program(s) for which application is being submitted. Please print clearly when completing the application. ADULT