Intake Application Please complete all sections of this application and do not leave any blanks. Please print.

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Return to CP Rochester 1000 Elmwood Ave. Suite 900 Rochester, NY 14620 585-295-1587 ext. 2281 Intake Application Please complete all sections of this application and do not leave any blanks.

1 Return to CP Rochester 1000 Elmwood Ave. Suite 900 Rochester, NY ext Intake Application Please complete all sections of this application and do not leave any blanks. Please print. Application is being made to the following program: (check one) Day Habilitation Free Standing Respite Community Habilitation In Home Respite Medicaid Service Coordination Care At Home Service Coordination Wraparound Respite Residential Supportive Employment TBI Service Coordination Community Recreation Respite NHTD Service Coordination 1. Consumer Information: Consumer Name: Last First MI Date of Birth: Mo/Day/Year [ ][ ][ ] Sex: Male; Female Social Security Number: [ ] [ ] [ ] Current Address: Street Phone number: ( ) Medicaid Number: Medicare: BC/BS Number: Other Insurance: 2. In case of emergency, the following person(s) are to be called: Name: Last First MI Relationship: Parent, Guardian, Other Current Address: Street Home Phone: ( ) Work Phone: ( ) If unable to reach, call: Name: Last First MI Relationship: Parent, Guardian, Other Current Address: Street Home Phone: ( ) Work Phone: ( )

2 3. Race (please check one) Optional required only for funding purposes American Indian and Alaska Native Asian Black or African-American Hispanic Native Hawaiian and Pacific Islander White Other 4. Primary Language (communication skill) Secondary Language (communication skill) English English Spanish Spanish American Sign Language American Sign Language Symbolic (type ) Symbolic (type ) Communication device Communication device (type ) (type ) Non-verbal Non-verbal Other Other 5. Does this consumer have a court appointed guardian or custodian? No, Yes. If yes, please list below and attach documentation: Name: Last First MI Current Address: Street Home Phone: ( ) Work Phone: ( ) 6. Primary Health Care Provider Primary Physician: Address: Street Phone number: ( ) Fax: Hospital Affiliation Emergency on Call: 7. Name, Service Coordinator: Agency Affiliation: Address: Street Fax: Emergency On Phone number: ( ) Call#: 8. Does this consumer have any known allergies, for example, to foods, medications, or the environment? No, Yes. If yes, please list below include date and reaction: Intake Application page 2 of 10

3 9. Has this consumer ever been convicted of a felony or misdemeanor? No, Yes. If yes, please list dates and offense: 10.Does the consumer have a DNR order? No, Yes. If Yes, attach a copy to this form. Does the consumer have a Health Care Proxy? No, Yes. If Yes, attach a copy to this form. Does the consumer have a Living Will? No, Yes. If Yes, attach a copy to this form. 11.Describe the reason(s) this consumer is requesting services from CP Rochester. (Please attach separate sheet if necessary. Please do not state, refer to another document.) 12. Describe this consumer s disability history. Please include any special medical issues in the history. (Please attach separate sheet if necessary. Please do not state, refer to another document.) Height Weight Primary Diagnosis Secondary Diagnosis Comprehension Ability: comprehends verbal directions without problems understands simple directions does not understand simple directions understands Sign Language other, please describe: Intake Application page 3 of 10

4 13. Does the consumer demonstrate any of the behaviors below? Please Include Frequency BEHAVIOR YES NO DAILY WEEKLY MONTHLY Physical Aggression Wandering/Running Away Destroys Property Tantrums Self Injurious Behavior Verbal Outbursts Mouthing/Swallowing or eating non-food items Interactions with others that are not appropriate Other 14. Does the consumer have a current written behavioral plan? No, Yes. If Yes, please complete the following and attach current plan: If there is a plan where is it implemented? Has the plan been effective? Who wrote the plan and when was it written? Are there things that are more likely to cause the behavior to happen, please explain? If there is no plan in place how do you deal with the behavior? Is there anything else you would like us to know about this behavior that is important? Intake Application page 4 of 10

5 15. School/Program Information: Is the consumer attending school or a day program? Yes, No If Yes, please complete below. School or Program Name: Contact Name: Last First School/Program Address: Street Contact Phone number: ( ) Transportation Provider: Transportation Contact Name: Last Contact Phone number: ( ) First 16. Has this consumer ever had a seizure? No, Yes. If Yes, please answer the following: a. When was the last time the consumer had a seizure? b. How often does the consumer have a seizure? c. Please describe as fully as possible, a typical seizure episode, including physical characteristics, and duration. Describe any warning signs that a seizure is about to occur. Intake Application page 5 of 10

6 17. Social and Recreational Activities a. Describe how the consumer interacts with peers, younger children and authority figures. b. Describe the consumer s favorite activities/hobbies? What supports or supervision are needed to participate in these activities? c. Are there any special concerns when the consumer is in the community (on an outing for example). What supports or supervision are needed to participate in these activities? (Please include pedestrian skills, ability to interact safely with strangers. d. Does the consumer have any special travel needs such as a wheel chair, person to accompany them, special accommodations, or supervision? What supports or supervision are needed to participate in these activities? 18. What is the consumer s diet and the consistency of the food? a. Does the consumer need assistance or supervision when eating? No, Yes. If Yes, please specifically list the type of assistance needed, including adaptive equipment needed. b. Please detail any specific food/meal likes, dislikes, and/or special considerations required to assist and/or encourage this consumer to eat. Intake Application page 6 of 10

7 c. Approximately how long does it take this consumer to eat meals and are they at risk for choking? d. Medical restrictions to diet (diabetic, low sodium, low cholesterol, gluten free, low calorie)? 19. How does the consumer ambulate? a. Does this consumer walk independently? Yes, No. If No, please describe any assistance needed. Please include any mobility restrictions and pre-cautions. b. Does this consumer use aids for mobility? No, Yes. If Yes, please describe the type and how the consumer utilizes them (for example, walker, rolling walker, manual wheelchair, power wheelchair). 20.How does the consumer transfer? a. Does this consumer transfer independently? Yes, No. If No, please describe any assistance needed for the consumer to transfer (for example, one person assistance, two person assistance, stand and pivot, etc.) Please include any mobility restrictions, pre-cautions and special aides used (for example, Hoyer lift.) b. Does this consumer use aids for transferring? No, Yes. If Yes, please describe the type and how the consumer utilizes them (for example, walker, rolling walker, etc.) Intake Application page 7 of 10

8 21. What is the consumer s evacuation capability? Is the consumer able to leave a building by himself or herself during an emergency? Yes, No. If No, what type of support/assistance is needed? 22. Is this consumer continent of bowel? Yes, No. Is this consumer continent of bladder? Yes, No. If No to either question, please describe toileting needs and routines, including the use of adult continence products. Will the consumer ask for toileting assistance? Yes, No. Will the consumer be aware if he or she is incontinent? Yes, No. 23. Please list the type and use of all adaptive equipment used by this consumer. Please include helmets, AFOs, braces, utensils, etc. 24. Does this consumer need special bed safety equipment, for example, bed rails? No, Yes. If Yes, please describe the type of equipment needed. Intake Application page 8 of 10

9 25. Does this consumer wear glasses or corrective lenses? No, Yes. If Yes, please describe, including any special care considerations. 26. Does this consumer use any hearing or communication aids? No, Yes. If Yes, please describe, including any special care considerations. 27. Medication Regimen: Please list all current medications. Medication How Much How Often Why is Medication Taken Prescribing MD Specialist Intake Application page 9 of 10

10 28. Special Needs for Medications. a. Does this consumer have any special needs to enable them to take medication, such as taking the medication in pudding, applesauce, etc? This may be such things as taking the medication with a special food, with a special cup or spoon, or in a special way. No, Yes. If Yes, please describe those special needs. b. Is this consumer capable of self-medication administration? No, Yes. If Yes, please describe any special needs and supports needed by this consumer for self-medication administration. c. Does this consumer have any medical health issues that have not been covered in this application? After signing below please attach the following documents: Current ISP Current Psychological Assessment Current Physical Completed HIPAA forms Notice of Decision or Documentation of Disability Copy of DDP2 Current PPD Thank you for completing this form. Print Name of person completing this form Relationship to Consumer Signature of person completing form Date Intake Application page 10 of 10

TRINITY ASSISTANCE CORPORATION

TRINITY ASSISTANCE CORPORATION Return Application to: Trinity Assistance Corporation 3545 Buffalo Road, Ste. 2 Rochester, NY 14624 Fax: (585) 978-3555 Community Program Intake Application Hourly Respite-Inhome