Completed by:	Relationship:
Service Coordinator:	Date completed:
Agency:
Address:	Phone # (w/ Ext.):	Fax #:	E-Mail:

Application Data

NAME:	Phone #:	Tabs #:	DOB:
Address:	Current Living Situation:
City:	County:		Zip Code:		Gender: Citizenship:		Religion:	Social Security #:

Primary Language:

Vaccinated:	Mask compliment Medicaid#:

Developmental Disabilities

Intellectual Disability: (Select One)

Mild

Moderate

Severe

Profound

Epilepsy:

Cerebral Palsy:

Autism:

Neurological Impairment:

Psychiatric diagnosis:	Other:

Verbal:	Non-verbal (please specify):
Ambulatory:	Yes	No	Stairs:	Yes	No - Explain any Mobility Supports needed: Level of Supervision required in the Home:
Level of Supervision required in the Community:

Number of adults residing in home receiving services:
Number of children residing in home receiving services:
Do these children receive OPWDD services?	Yes	No
Family		Caregiver		Emergency Contact (Select One) Name:	Relationship:			Primary Language: Address:			City:	Zip:
Home #:	Work #:	E-Mail:
Legal Guardian	Advocate Information (Select One) Name:	Phone #:		Primary Language:
Address:	City:	Zip:
Home #:	Work #:	E-Mail:

Emergency Information

Hospital:
Health Insurance Co.:
Policy #:	Name on Policy:
Medicare #:	Medicaid #:
DNR Order:	Yes	No	Health Care Proxy:	Yes	No	Living Will	Yes	No

Medical Information (attach any additional information)
Name of Primary Physician:
Address:	Date Last Seen:
Name of Dentist:
Address	Date Last Seen: Additional Physicians (i.e.: psych) Physician:		Specialty:
Physician:	Specialty:
Physician:	Specialty:

Present Medications

Pharmacy:	Phone #:
Drug
1)			Dosage	Times Given	Reason	How Administered/By Whom	Route Given
.	
2)							.	
3)							.	
4)							.	
5)							.	
6)							.	
Height:	Weight:	Seizures:	Yes	No Description:				

Visual Impairments:

Yes

No Wears Glasses:

Yes

No Legally Blind:

Yes	No

Hearing Impairments: Allergies: Yes Allergy

Yes No

No	Wears Hearing Aid: Typical Reaction

Yes	No

Treatment

Special Medical Needs	
Suctioning:	Yes	No	Respiratory Therapy:	Yes	No	Injections:	Yes	No	Oxygen:	Yes	No	
Dressing/Wound	Care:	Yes	No	
Other:		
Health Concerns:		
Surgical History:		

Income Sources (Residential Only)

SSI $	SSD $		Public Assistance $	Food Stamps $	Other income $ Waiver enrolled:	Yes	No	Other Funding Source:
Assets (Life insurance, trust funds, Burial funds, Property, CD’s):

Transportation Abilities (Circle all that apply)

Public Transportation Other:

Family provides transportation

Medicaid cab

Drives own car

Current Agency Affiliations (i.e.: OPWDD, DSS, CASA)

Service Provided:	Agency Providing: Address:
Phone #:	Contact Name:
Service Provided:	Agency Providing: Address:
Phone #:	Contact Name:
School / Day Service:
Address:
Phone #:	Contact Name:

Fire Evacuation Ability

Will respond to fire alarm

Yes

No	Will leave house independently

Yes

No	Needs help to leave

Yes	No

Verbal prompts Total Assistance

Yes Yes

No	Physical assistance No

Yes	No

Meal Time

Independent    Needs Help    Dependent	Independent  Needs Help	Dependent	Independent Needs Help Dependent
Feeds Self	Drinks	Pours Drink
Cuts Food	Cleans Self	Bottle Fed

Yes	No	Yes	No	Yes	No
Utilizes G- Tube feeding:	Spoon:	Fork:
Adaptive Feeding Equipment:	Plate:	Cup: Other:

Are there any difficulties eating due to: (Check all that apply)

Drooling

Bite Reflex

Gagging

Chewing

Sucking

Choking

Swallowing

Unable to close mouth

Biting pieces of food	Eats slowly?
Describe how to best assist the person during eating: Special Diet:	Food Allergies:
Favorite Foods:	Disliked Foods:

Dressing / Toileting

Wears briefs/Diapers:

Yes

No	Toilet Schedule:

Yes

No	Adaptive Equipment:

Yes	No

Independent / Needs help / Dependent	Independent / Needs help / Dependent	Independent / Needs help \ Dependent

Dresses self

Zips

Socks

Pants

Buttons

Tie Shoes

Shirt

Undergarments

Select Clothes

Undresses self

Manages clothing

Washes hands

Transfers from chair to toilet

Initiates

Manages toilet tissue

Self toilets
Are there any special problems with bowel movements and/or urinary problems? (Explain)

Self - Care

Independent / Needs help \ Dependent	Independent  \ Needs help \ Dependent	Independent \ Needs help \ Dependent

Washes Body

Brushes Teeth

Tub/Shower

Shampoos Hair

Combs Hair

Menstruation Care

Sleep Patterns

Wears to bed:	Bedtime:	Wake-up time:
Sleeps through the night:		Yes	No	Uses bed rails:	Yes		No		Door:	Open	Closed Lights:	On	Off	Toileted/Changed during night:	Yes	No	If yes, what times:
Naps:	Yes	No	If yes, what times: Bedtime routine / Problems:
Positioning: Other:

Behavior

Indicate frequency of behavior by using code:  D = Daily,	W = Weekly,	M = Monthly,	N/A = Not Applicable
No Problems:	Eats In-edibles:		Wanders/runs away: Destroys property:		Non-compliance:		Bites: Inappropriate sexual behavior:	Other:
Hits / Kicks:		Verbal Abuse:		Self injurious behavior: Smokes:	Pulls Hair:	Spits:
Precipitating factors/causes:
How are these behaviors supported?
Reinforcers:
Sexuality – Consenting:	Yes	No Comments: Interests or Hobbies (please explain):
Dislikes (please explain):
Fears (please explain):

Additional information not previously covered: Any Legal Issues (Please Explain):

Residential Need

Group setting:

Intermediate Care Facility (ICF)

Family Care

Apartment style:

Supportive

Supervised

All Male Activity in Home:

All Female Very Active

Co-Ed	Shares Bedroom: Fairly Active		Less Active

Yes	No

NY State Cares enrolled:	Yes	No
Other Information (i.e.: pets):
Reason for Residential Request:
County Preference:	Allegany		Cattaraugus	Chautauqua	Chemung	Erie	Genesee	Livingston	Monroe	Niagara Ontario	Orleans	Schuyler	Seneca		Stueben		Wayne	Wyoming	Yates
How soon is placement desired:	Urgent	Under 2 years	3-5 years	5 or more years?

Services Requested

Respite:	Habilitation:	Behavior Services:
Respite – In Home	Day Habilitation (Group)	Enhanced Supported Employment** Respite - Out of Home	Community Habilitation		Intensive Behavior Support**
Respite – Weekend	Assistive Supports	** If this service is requested, please attach updated DDP-2 Respite – After School	Day Habilitation (Supplemental)		& OPTS Non-IRA enrollment form.
Prevocational	Supported Employment (SEMP)

Number of Respite Hours:	Requested Start Date:
Number of Community Habilitation (Res Hab) Hours:

Explain in detail the goal of utilizing this service, and how efficiency of such will be measured:

Please attach current ISP/addendum, DDP1, transmittal sheet, and **DDP-2 & OPTS Non- Enrollment form (as applicable)