Charlottesville Rosser House

For people with intellectual and developmental disabilities

APPLICATION: COMMUNITY SUPPORT SERVICES

Personal Information

GUIDELINES

Emergency Contact Person

SOCIAL & DEVLOPMENTAL SUMMARY

FAMILY SUMMARY

MEDICAL HISTORY

Indicate if the Applicant has any of the following illnesses, and/or chronic conditions

MEDICATION PROFILE

SUPPORT

HISTORY OF RESIDENTIAL TREATMENT OR INSTITUTIONALIZATION:

FOR OFFICE USE ONLY

Application for Services

Application for Services

$10,000 GOAL!!

2020 Annual Giving Matching Campaign

Please help The Arc of the Piedmont reach our goal to receive a generous matching donation!!

Group Home for up to five individuals located in the Rosser Road neighborhood around the corner from our Activity Center on Rose Hill Drive.

Manager: Maria Allen, MAllen@arcpva.org

Please fill out our application for services below.

APPLICATION: COMMUNITY SUPPORT SERVICES
Check the services for which you are applying:*
- Group Home
- In-Home
- Sponsored Residential
- Group Day Support
- Respite
- Community Engagement
- Community Coaching
Personal Information
Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Social Security Number*
Medicaid #*
Medicare #
Other Insurance? (Name of Company)
Group #
Policy #
Address*
Street Address City State ZIP Code
Phone*
Sex*
Race*
Height*
Weight*
Hair & Eye Color*
Marital Status
- Married
- Single
- Divorced
Citizenship?*
- Yes
- No
Primary Oral Language?*
Primary Written Language*
Interpreter Needed?
- Yes
- No
Religion?
Birthplace?
Diagnosis?*
Adaptive Equipment?*
- Yes
- No
If yes, then please describe...
Has the court named someone as the legal guardian?*
- Yes
- No
If so, give the guardian's name, address and phone number
Criminal Justice Status
GUIDELINES
Special Diet*
Eating*
Communication*
Mobility*
Supervision*
Emergency Contact Person
Name*
First Last
Address*
Street Address City State ZIP Code
Day Phone*
Night Phone
Email*

Emergency Orders
Hospital Preference?
Relationship*
WAIVER?*
- Yes
- No
SOCIAL & DEVLOPMENTAL 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
Father's Name*
First Last
Father's Occupation*
Father's Address*
Street Address City State / Province / Region ZIP / Postal Code
Father's Phone*
home
Father's Phone
Work/cell
Father's Email*
Mother's Name*
First Last
Mother's Occupation*
Mother's Address*
Street Address City State / Province / Region ZIP / Postal Code
Mother's Phone*
home
Mother's Phone
Work/ Cell
Mother's Email*
Brothers & Sisters (Name, Age, Sex)*
Other relatives 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
Indicate if the Applicant has any of the following illnesses, and/or chronic conditions
A. Epilepsy, CP, MS, Parkinson's Neuritis, Paralysis, Alzheimer's disease or any other disease of the central nervous system.*
- YES
- NO
B. Heart attack, murmur or palpitation or high blood pressure, anemia, varicose veins, or any other disease of the heart, blood or blood vessels.*
- YES
- NO
C. Tuberculosis, asthma, pleurisy, or any other disease of the lungs, brachial tubes, throat or respiratory systems.*
- YES
- NO
D. Ulcer, indigestion, colitis, gall stone, hernia, or any other disease of the stomach, intestines, rectum, gall bladder or liver.*
- YES
- NO
E. Urinary sugar, albumin or stone, sexually transmitted disease, menstrual disorder, or any other disease of the breasts, kidneys, prostate, urinary or genital systems.*
- YES
- NO
F. Diabetes, gout, or any other disease of the thyroid or other glands.*
- YES
- NO
G. Arthritis, rheumatic fever, back trouble or any other disease of the joints, muscles, or bones.*
- YES
- NO
H. Clinical Depression, Schizophrenia, Bipolar Disorder, or any mental illness.*
- YES
- NO
I. Intellectual Disability, Autism, or any other development disability.*
- YES
- NO
If you answered "yes" to A-I above, then list all that apply.
Current significant medial 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:*
MEDICATION PROFILE
MEDICATIONS*
Name Dosage Times Taken Reason Side Effects

Click + on right to add more
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?*
- YES
- NO
- UNKNOWN
Are seizures under control?
- YES
- NO
- PARTIALLY
- UNKNOWN
Are seizures controlled
- with medication?
- without medication?
Blood Type:*
SUPPORT
Applicant can be without supervision for:*
- Up to 15 minutes
- Up to 1 hour
- All day
- Overnight
- 48 Hours
- with weekly contact
- other
If other:
Motor Skills-How frequently does applicant require support or assistance in walking and standing?*
- Rarely
- Sometimes
- Often
- Always
Does the applicant use a:
- Walker
- Wheelchair
- other
If other:
Social and communication skills- How frequently does the applicant require support in among his or her needs known or getting along with others?*
- Rarely needs help
- Sometimes needs help
- Often needs help
- Always needs help
What is the applicant's primary means of communication?*
- Verbal Speech
- Gesture, Communication Board
- Sign Language
- Vocalization (no speech)
Personal living skills: How frequently foes the applicant require support with eating, dressing, using the bathroom, or personal hygiene?*
- Rarely
- Sometimes
- Often
- Always
Community Living Skills: How frequently does the applicant require support with being safe around traffic, recognizing an emergency, telling time, shopping, or working?*
- Rarely
- Sometimes
- Often
- Always
Engagement: How often does the Applicant need support engaging with Community members?*
- Rarely
- Sometimes
- Often
- Always
Advocacy: How often can the application advocate for him/herself?*
- Rarely
- Sometimes
- Often
- Never
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 (to/from)

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Other Social Service Agencies/ Professionals Involved:
Agency/ Professional Dates (to/from) Contact Person/ Case Manager
Additional Comments:
This Form must be accompanied by the following:
- 1. SIS (CBS case manager can provide)
- 2. Consent to exchange Information (CBS case manager can provide)
- 3. Report of physical, which includes:
- a. general physical condition
- b. evaluation for communicable diseases (TB screen)
- c. recommendations for further treatment
- d. other examinations indicated
- e. the date of the exam and signature of medical provider
- 4. Copy of Medicaid/ Medicare Card
- 5. Copy of Birth Certificate
- 6. Copy of Phycological Report
- 7. Copy of Dental Records
Form Completed by:*
Relationship to Applicant:*
Date:*
Date Format: MM slash DD slash YYYY
FOR OFFICE USE ONLY
Date application was received
Date Format: MM slash DD slash YYYY
Admission Date
Date Format: MM slash DD slash YYYY
Discharge Date
Date Format: MM slash DD slash YYYY

« Jan 2021 »

Name	Dosage	Times Taken	Reason	Side Effects

Name of Agency or Institution	Address	Dates (to/from)

Agency/ Professional	Dates (to/from)	Contact Person/ Case Manager