Dr. George C. Simmons Counseling & Support Center 585 Joseph Ave. Rochester, NY 14605 (585) 325-8130 - (585) 546-1491 fax To Whom It May Concern: This letter is to introduce Baden Street Settlement s MSC program. We like to inform you of the many programs that are available for you and your student (whom may be in special education program). We have MSC, which is a service coordinator (case management) program that assists student/family in navigating the complexity of services that are available to them (on behalf of their child). We make linkage and referrals along with advocating for student/family. We also have within our department a unique after school program/hourly respite that provides your child with recreation and tutorial services. There is also a light meal given before your child leaves program, along with transportation home. This program allows your child the opportunity to enjoy recreation (safely) along with providing the family with additional time to handle day to day duties. This program runs 5 days a week, after school hours. We hope you complete information provided for Baden Street Settlement to begin the evaluation process for your child, if you care to visit our facilities or have any questions, please feel free to contact: After School Program MSC Service Coordination Pam Quick Stephanie Jones (585) 317-4402 (585) 325-8130 ext 204 Leave name and message with return number for contact Respectfully, MSC Dept. Baden Street Settlement 1
Dr. George C. Simmons Counseling & Support Center 585 Joseph Ave. Rochester, NY 14605 (585) 325-8130 - (585) 546-1491 fax Registration Application for Services Date of Application: Date Service Needed: Date/Time Received: SERVICE REQUESTED (check desired services): MSC SERVICES Service Coordination After School program Hourly Respite IDENTIFYING INFORMATION Name: LAST FIRST MIDDLE Date of Birth: Social Security #: Medicaid #: Sex: M F Address: City: State: Zip Phone #: Is consumer OPWDD Waiver enrolled yes no Family / Advocate: NAME RELATIONSHIP Family / Advocate Address: Phone #: 2
Dr. George C. Simmons Counseling & Support Center 585 Joseph Ave. Rochester, NY 14605 (585) 325-8130 - (585) 546-1491 fax Other Involved Family Members: NAME RELATIONSHIP NAME RELATIONSHIP NAME RELATIONSHIP Service Coordinator (if there is one): Phone #: Agency: Service Coordinator Address: Referring Person: Phone #: Signature of Referring Person: Date: Consent to release needs to be completed (signed by parent/guardian) for referral process to be completed and reviewed. Please attach all information available, that is noted in the consent to release 3
CONSENT FOR RELEASE OF INFORMATION I hereby authorize the release of information to Baden Street Settlement, MSC Department. The purpose of this disclosure is referral for services. I understand that this authorization covers the information listed below and any additional information necessary for the purpose of assessing eligibility for services. Baden Street Settlement, MSC Department will maintain the confidentiality of this information. Baden Street Settlement, MSC Department will not release this information. Information to be released: (Please check all that are available and if attached) Date: Available: Attached: Baden Street Settlement, MSC Department Yes No Yes No Application for Services: Psychological Assessment: Yes No Yes No Social Assessment: Yes No Yes No Physical Exam: Yes No Yes No Individualized Service Plan: Yes No Yes No Individualized Education Program (IEP): Yes No Yes No Behavior Support Plan: Yes No Yes No DDSO Risk Assessment (if applicable): Yes No Yes No Notice of Decision: Yes No Yes No Hep B Screening & PPD Test Results: Yes No Yes No Person Centered Plan: Yes No Yes No DDP-2: Yes No Yes No Other: Yes No Yes No In addition, I authorize representatives of Baden Street Settlement, (MSC Department) to make inquiries and/or visits to current service providers in order to make an informed determination regarding placement. Applicant s Signature Advocate / Legal Guardian Date Date Applicant s Address Relationship NOTE: THIS CONSENT MAY BE REVOKED AT ANY TIME BY PUTTING SUCH REQUEST IN WRITING. Submit any information (from list) you currently have with application. 4
LIVING SKILLS ASSESSMENT For registration into after school program / hourly respite program * Please complete information (if applicable) to ensure registration be processed in timely fashion* Name of Applicant: Date of Birth: LEVEL OF SUPERVISION NEEDED: (Please mark Total Support, Assistance, Supervision, or Independent ) Self Care: Toileting: Dressing: Eating: Bathing: Menses Care: Grooming: Is the individual self-preserving (able to independently get themselves out of a house in the event of a fire)? Yes No TRANSPORTATION: Able to use Liftline Able to use RTS Can take taxi Has own car Has driver s license, no car Potential for travel training MOBILITY STATUS: Ambulatory Uses manual wheelchair Can negotiate stairs Requires use of lift One person transfer Several person transfer Can bear weight Can be transported in a car Requires vehicle w/ lift for wheelchair HEALTH PROBLEMS / MEDICAL / PHYSICAL LIMITATIONS: (Including hearing, vision status, seizure disorder, and any other medical conditions) CURRENT MEDICATION (list all): Capable of self medication: Yes No 5
COMMUNICATION: Primary language: Verbal? Yes No Uses sign language Requires interpreter Receptive / expressive communication skills: CURRENT CLINICAL SERVICES: Occupational Therapy Physical Therapy Counseling Social Work MD Speech Therapy Other: ADAPTIVE EQUIPMENT REQUIRED: Communication Device Feeder Computer Mobility Aids Facilitated Communication Lift Other: BEHAVIORAL SUPPORTS REQUIRED: Does the applicant have a Behavior Support Plan (if yes, please attach a copy of the plan)? Yes No Does the applicant have a history of starting fires? Yes No INTERESTS / HOBBIES: 6
Dr. George C. Simmons Counseling & Support Center 585 Joseph Ave. Rochester, NY 14605 (585) 325-8130 - (585) 546-1491 fax Attachments: Please attach all documents listed: Document Needed: Document Date: Individualized Service Plan (reviewed within the past 6 months) Individualized Education Plan (if applicable and within the past 6 months) Complete Physical Exam (within the past 12 months) List of Current Medications DDP -2 Psychological Evaluation Psychiatric Evaluation (if individual has Psychiatric Diagnosis) Current Behavior Plan (if applicable) DDSO Risk Assessment (if applicable) Program Plans and Plan of Protective Oversight (if enrolled in any current services) Clinical Evaluations ( if applicable and within the past year) Notice of Decision Level of Care Eligibility Determination (LCED) Legal Guardian Paperwork (if applicable) 7
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