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

The Nelson Day Support Program is located at the American Legion building in Shipman VA just a few miles from Lovingston VA. The Day Support Program assists adults with intellectual and developmental disabilities to be more independent, learn new things, visit new places and make new friends. We provide individualized training in daily living skills, socialization and communication. Activities and experiences are designed to enable individuals to achieve their highest potential in interdependence and participation in the community.

For more information contact:
Karen O’Rourke

Deputy Director for Program Services
(434) 977-4002 or korourke@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

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

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