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Application for Consumer Services
BAYSIDE COMMUNITY NETWORK
INTAKE APPLICATION
Please check which service you are applying for and which services you are interested in receiving.
Day Habilitation
Residential
Respite
Supported Employment
Supported Living
Community Development Services
Employment Discovery & Customization
GENERAL INFORMATION
1. Applicant Information:
Consumer Name:
First Name:
Middle Name:
Last name:
Date of Birth:
Sex:
Male
Female
Marital Status:
Single
Married
Divorced
Widow
Social Security Number:
Current Address:
Street:
City:
State:
Zip:
Phone Number:
Home:
Cell:
Email Address:
Medicaid Number:
Other Insurance:
Number:
2.In case of emergency, the following person (s) are to be called:
Name:
Relationship:
Current Address:
Street:
City:
State:
Zip:
Home Phone:
Cell:
Work:
Email Address:
If unable to reach, call:
Name:
Relationship:
Current Address:
Street:
City:
State:
Zip:
Home Phone:
Cell:
Work:
Email Address:
3. School/Program Information:
Is the applicant attending school or receiving services at another agency?
Yes
No
If at an agency, what services are currently being provided?
School or Agency Name:
Contact Name:
Address:
Street:
City:
State:
Zip:
Contact Number:
Phone Number:
Fax:
Contact Email Address:
Will applicant be receiving services at another agency while attending Bayside Community Network?
Yes
No
If yes, please provide the following information:
What services are being provided by other agency?
What is agency name?
Contact Person at Agency:
Address:
Street:
City:
State:
Zip:
Phone Number:
Fax Number:
Contact E-mail:
4. Resource/Service Coordinator:
Name:
Agency Affiliation:
Address:
Street:
City:
State:
Zip:
Office Contact:
Phone:
Fax:
Email:
5. Does applicant have a court appointed guardian or custodian?
No
Yes
If yes, Please list below and attach documentation:
Name:
Relationship:
Current Address:
Street:
City:
State:
Zip:
Home Phone:
Cell:
Work:
Email:
6. Language:
Primary Language:
English
Spanish
American Sign Language
Communication Device
Gestures
Non-verbal
Other
Type:
Secondary Language:
English
Spanish
American Sign Language
Communication Device
Gestures
Non-verbal
Other
Type:
Communication Ability:
effectively communicates wants/needs
can carry on a conversation
utilizes alternative communication
requires a translator (specify person/agency)
requires prompting/cueing to initiate conversation
has difficulty with articulation/speech
requires prompting/cueing to engage in conversation
Specify:
Comprehension Ability:
comprehends verbal directions without problems
understands simple directions
does not understand simple directions
understands Sign Language
other
Please Describe:
7. Describe the reason this applicant is requesting services from Bayside Community Network, Inc.
(Please attach a separate sheet if necessary. Please do not state “refer to…” another document):
8. Describe the applicant’s disability history.
Please include any special medical or mental health issues in the history. (Please attach a separate sheet if necessary. Please do not state “refer to …” another document)
Height:
Weight:
Primary Diagnosis:
Secondary Diagnosis:
9. Has applicant ever been convicted of a crime?
Yes
No
If yes, please list below:
The applicant is currently on
Probation
Parole
Parole for the following charge:
List any specific conditions of parole/probation:
Probation/Parole is expected to end on:
10. Does applicant have a history of behavioral challenges or a current behavior plan?
Yes
No
If yes, please complete the following
Will this plan need to be utilized while the consumer receives services?
Yes
No
If yes, please attach the plan including the consents
What specific behaviors does the plan address? Please describe the behavioral challenges.
What triggers these behaviors?
How long has the plan been in place?
Does the applicant currently receive 1:1 staff supports?
Yes
No
If yes, how many hours per day/week are these supports provided
11. Does the applicant see a Psychiatrist and/or Counselor/Therapist?
Yes
No
PsychiatristName:
Address Street:
City:
State:
Zip:
Frequency Visits:
Counselor/Therapist:
Name
Address Street
City
State
Zip
12. Cognitive Status: (please check all that apply)
Orientation to:
time
place
person
activities
day/week
needs prompting/cueing for orientation
easily confused
not oriented
Attention/Concentration:
able to stay on task independently
easily distracted
needs occasional verbal cues/prompts to stay on task
requires constant cueing/prompting to stay on task
day/week
needs prompting/cueing for orientation
easily confused
not oriented
Initiation:
initiates activities
requests assistance when needed
ability varies for ADL’s
needs prompts/cues to initiate tasks/activities
cannot initiate tasks/activities
Memory:
memory is functional for day-to-day activities
short term memory difficulties
long term memory difficulties
Organization:
good organizational skills
ability varies based on task/activity
needs prompting/cues for organizational skills
needs others to provide organization
Problem-Solving/Judgment:
aware of current skills/limitations
makes reasonable decisions
needs cues/prompts for problem-solving
unable to engage in problem-solving activities
Learning Abilities:
able to follow one-step directions
able to follow multi-step directions
interested in and willing to learn new strategies/tools
not able to follow directions.
Other details regarding cognitive status:
13. Social and Recreation Activities:
Describe how the applicant interacts with the following:
Peers:
Younger/Vulnerable People:
Authority Figures:
Describe the applicant’s favorite hobbies/activities.
Please include what supports or supervision Is needed to participate in these activities:
Please list any activities the applicant strongly dislikes:
Describe any strong fears the applicant may have:
Does the applicant have the ability to understand and handle money?
Yes
No
Handling limit
Are there special concerns when the applicant is in the community?
Please include what supports or supervision is needed to participate in the community outing.
Does the applicant have any special travel needs:
Please provide additional information if checked:
manual wheelchair
electric wheelchair
person to accompany
special accommodations
Can the applicant drive?
Yes
No
14. Can the applicant evacuate building during an emergency?
If no, please describe type of assistance/supports
Yes
No
15. ADLS/IADLS:
Basic ADLS (Eating, Dressing, Toileting, etc.):
independent
needs verbal prompting
needs physical prompting
needs hands-on assistance
needs total support
Is this applicant continent of bladder?
Yes
No
Is this applicant continent of bowel?
Yes
No
Is this applicant able to care of feminine hygiene needs?
Yes
No
Will the applicant ask for toileting assistance?
Yes
No
Will the applicant be aware if he/she is incontinent?
Yes
No
If no to any of the above questions, please describe the toileting/hygiene needs and routines, including the use of adult continence products
Household Activities (Meal Prep, Laundry, etc.):
independent
needs verbal prompting
needs physical prompting
needs hands-on assistance
must be completed by others
IADLs (Shopping, Banking, etc.):
independent
needs verbal prompting
needs physical prompting
needs hands-on assistance
must be completed by others
Endurance/Strength:
able to engage in routine activities
experiences periodic fatigue
fatigues easily
requires frequent rest periods
needs physical assistance to engage in routine activities
MEDICAL INFORMATION
16. Does this applicant have any known allergies?
Yes
No
If yes, please list all allergies including food, medication, and environmental allergies:
Does the applicant use an Epi-Pen for any allergies?
Yes
No
17. Does applicant have a DNR order?
Yes
No
If yes, please attach a copy
Does applicant have a Health Care Proxy?
Yes
No
If yes, please attach a copy
Name of Health Care Proxy:
Name of Alternate Health Care Proxy:
Does applicant have a Living Will?
Yes
No
If yes, please attach a copy
Does applicant have a Power of Attorney?
Yes
No
If yes, please attach a copy
18. Has this applicant ever had a seizure?
Yes
No
When was the last time the applicant had a seizure?
How often does the applicant have a seizure?
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:
How often does the applicant see the physician who treats their seizures?
Is the applicant taking medication(s) to control their seizures?
Yes
No
If yes, what medication(s) is the applicant taking to control their seizures?
19. Dietary Regulations: (please check all that apply)
Regular
Low sodium
Low fat
Low cholesterol
Diabetic diet
Renal diet
Cardiac diet
Nutritional supplement
Swallowing Difficulties: (please check all that apply)
None
Pureed food
Ground consistency
Chopped consistency
Thickened liquids
Tube feeding
Aspiration precautions
Aspiration precautions (please explain)
Adaptive Equipment: (please check all that apply)
Plate/Bowl
Utensils
Cup
Dentures:
None
Partial
Upper
Lower
Special Dietary Considerations: (e.g. vegetarian, kosher, etc.)
Describe any specific information that pertains to the applicant’s ability to eat and drink:
20. Mobility:
Mode of Ambulation:
independent
supports/gait belt
cane
walker
wheelchair/scooter
unable
Ability to Ambulate:
independent
needs periodic supervision/support
needs ongoing supervision/support
one person assist
two person assist
unable
Ability to Transfer:
Independent
Needs periodic supervision/support
Needs ongoing supervision/support
One person assist
Two person assist
Mechanical lift
Unable
Other
Other
21. Smoking:
Does the applicant smoke?
Yes
No
Can the applicant smoke without supervision?
Yes
No
Can the applicant safely keep his cigarettes/lighter on his person or in his room?
Yes
No
22. Durable Medical Equipment:
Supply Equipment Item
Purpose of Equipment
Prescribed by and phone number
23. Hearing Ability:
Hears adequately
Hearing difficulty
Uses hearing aids
Uses other device
Other Device
Hearing impairment effects:
Right ear
Left ear
Please describe any specific information that pertains to the applicant’s ability to hear:
Is the applicant able to operate/clean their hearing aid (s)?
Yes
No
If no, please describe what assistance is required to operate and/or clean the hearing aid (s)
Does the applicant frequently lose and/or misplace their hearing aids?
Yes
No
24. Visual Acuity:
Vision is adequate for daily activities
Vision impaired
Right eye
Left eye
Wears glasses
Needs large print
Cataracts
Right eye
Left eye
Legally Blind
Right eye
Left eye
Uses Braille
Eye Prosthesis
Right eye
Left eye
Guide Dog
Other
If other, please specify
Please describe any specific information that pertains to the applicant’s vision:
Is applicant able to independently clean their glasses?
Yes
No
Does applicant frequently lose and/or misplace their glasses?
Yes
No
25. COVID ***Please be advised all participates of Bayside Community Network MUST be vaccinated for COVID unless you have a reasonable exemption due to a medical reason or because of a sincerely held religious belief.
Has the applicant been fully vaccinated for COVID?
Yes
No
If no, has the applicant had 1 shot for COVID?
Yes
No
If no, is applicant planning to be vaccinated for COVID?
Yes
No
Are you requesting a religious or medical exemption?
Yes
No
*if yes, additional forms will be sent to you for you to complete Has the applicant had COVID?
Yes
No
26. Medication Regimen: Please list all current medications:
repeater_title
1
Medications
(prescription and over the counter)
Dosage
Route
Frequency
Purpose
Prescribing Physician
Other Physician:
repeater_title
1
Specialty
Name
Office Address
City
State
Zip
Office Phone
Office Fax
***IT SHOULD BE NOTED THAT BAYSIDE COMMUNITY NETWORK WILL BE REPRESENTATIVE PAYEE FOR ALL RESIDENTIAL CONSUMERS. (RESIDENTIAL APPLICANTS ONLY)
Thank you for completing this form:
Name of Person completing this form
Relationship to Applicant
Phone Number:
Signature of Person completing this form:
Clear
Cell Number:
Email Address:
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