Application for Services

Application: Community Support Services

Personal Information

Name *first, middle, last

Date of Birth *

Month *

Day *

Year *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Phone Number *

Sex *

Race *

Height *

Weight *

Hair and Eye Color *

Marital StatusMarriedSingleDivorced

Citizenship *YesNo

Primary Oral Language *

Primary Written Language *

Interpreter Needed? *YesNo

Religion?

Birthplace?

Diagnosis? *

Supports Intensity Scale (SIS) Level and Tier

Adaptive Equipment? *YesNo

If yes, please describe: *

Has the court named someone as the legal guardian? *YesNo

If yes, give the guardian's name, address, and phone number.

Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Phone Number

Social Security Number *

Medicaid #

Medicare #

Other Insurance?

Group #

Policy #

Supports

Special Diet *

Eating *

Communication *

Mobility *

Supervision *

Emergency Contact Person

Name *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Day Phone *

Night Phone

Email Address *

Relationship

Hospital Preference

Social & Developmental Summary

Describe the Applicant's Previous Service History (Services Received; Dates of Service) *

Describe the Applicant's support needs, individual's stated needs, skill-building goals, psych, expected duration: *

Documentation of needs for service (Describe what the Applicant & authorized rep hope to gain by participating in the service): *

Family Summary

Mother's Name *

Mother's Occupation *

Mother's Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Mother's Phone Number(s) *

Mother's Email Address *

Father's Name *

Father's Occupation *

Father's Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Father's Phone Number(s) *

Father's Email Address *

Siblings (Name, Age, Sex) *

Other relatives with interest/involvement with individual *

Describe the applicant's current family structure and relationship. Also describe the anticipated future involvement of the applicant's family (i.e. visits, phone calls, updates by staff): *

Medical History

A. Epilepsy, CP, MS, Parkinson's Neuritis, Paralysis, Alzheimer's disease or any other disease of the central nervous system. *YesNo

B. Heart attack, murmur or palpitation or high blood pressure, anemia, varicose veins, or any other disease of the heart, blood or blood vessels. *YesNo

C. Tuberculosis, asthma, pleurisy, or any other disease of the lungs, brachial tubes, throat or respiratory systems. *YesNo

D. Ulcer, indigestion, colitis, gall stone, hernia, or any other disease of the stomach, intestines, rectum, gall bladder or liver. *YesNo

E. Urinary sugar, albumin or stone, sexually transmitted disease, menstrual disorder, or any other disease of the breasts, kidneys, prostate, urinary or genital systems. *YesNo

F. Diabetes, gout, or any other disease of the thyroid or other glands. *YesNo

G. Arthritis, rheumatic fever, back trouble or any other disease of the joints, muscles, or bones. *YesNo

H. Clinical Depression, Schizophrenia, Bipolar Disorder, or any mental illness. *YesNo

I. Intellectual Disability, Autism, or any other developmental disability. *YesNo

If you answered "yes" to A-I above, then list all that apply. *

Current significant medical problems, communicable disease, or recent physical complaints of Applicant, if any: *

Past Significant medical problems of Applicant, if any (serious injuries, serious illnesses, or hospitalizations): *

Serious illnesses or chronic conditions of the Applicant's parents, siblings, and others in the same household, if any: *

Applicant's substance abuse history including onset of use, types of substances, frequency of use, quantity of use, method of administration, if applicable: *

Name, address, and telephone number of Applicant's physician(s), dentist, therapist, or other medical professionals

Name and RelationshipPrimary Care Provider, Dentist, Specialist, etc.

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Phone Number

Medication Profile

Field Group

Name

Dosage

Times Taken

Reason

Side Effects

List Applicant's Drug or Food Allergies *

Are there any medications or treatments that the applicant should not have? (please list all): *

History of seizures? *YesNoUnknown

Are seizures under control? *YesNoPartiallyUnknown

Seizures are controlledwith medicationwithout medication

Blood Type *

Support

If other, please describe. *

Motor Skills - How frequently does applicant require support or assistance in walking and standing? *RarelySometimesOftenAlways

The applicant uses a:walkerwheelchairother

If other, please describe. *

Social and communication skills - How frequently does the applicant require support in making their needs known or getting along with others? *RarelySometimesOftenAlways

What is the Applicant's primary means of communication? *Verbal SpeechGesture, Communication BoardSign LanguageVocalization (no speech)

Personal living skills: How frequently does the Applicant require support with eating, dressing, using the bathroom, or personal hygiene? *RarelySometimesOftenAlways

Community Living Skills: How frequently does the applicant require support with being safe around traffic, recognizing an emergency, telling time, shopping, or working? *RarelySometimesOftenAlways

Engagement: How often does the Applicant need support engaging with community members? *RarelySometimesOftenAlways

Advocacy: How often can the application advocate for themself? *RarelySometimesOftenAlways

Behavioral supports: Please describe any behavioral supports that have proven to be successful for the Applicant: *

History of Residential Treatment or Institutionalization

Name of Agency or Institution

Address

Dates (start/end)

Other Social Service Agencies/Professionals Involved

Agency/Professional

Dates (start/end)

Contact Person/Case Manager

Please provide the following:

SIS (CBS case manager can provide)
Consent to Exchange Information (CBS case manager can provide)
Report of physical, which includes
- general physical condition
- evaluation for communicable diseases (TB screen)
- recommendations for further treatment
- other examinations indicated
- the date of the exam and the signature of the medical provider (within the last 12 months)
- physician's orders for all medications (scheduled and PRN/OTC)
- immunization record
Copy of Medicaid/Medicare Card
Copy of Birth Certificate
Copy of Psychological Exam (dx ID/DD)
Copy of Dental Records

Form completed by *

Relationship to Applicant: *

Signature *

Date *

Application for Services

Personal Information

Supports

Emergency Contact Person

Social & Developmental Summary

Family Summary

Medical History

Medication Profile

Support

History of Residential Treatment or Institutionalization

Other Social Service Agencies/Professionals Involved

1149 Rose Hill Drive Charlottesville, VA 22903 (434) 977-4002

1149 Rose Hill Drive
Charlottesville, VA 22903
(434) 977-4002