Bayside Community Network | Developmental Disability Services and Programs Cecil County Maryland.

1. Applicant Information:

Consumer Name:

First Name:

Middle Name:

Last name:

Date of Birth:

Sex: MaleFemale

Marital Status: SingleMarriedDivorcedWidow

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? YesNo

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? YesNo

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?

NoYes

If yes, Please list below and attach documentation:

Name:

Relationship:

Current Address:

Street:

City:

State:

Zip:

Home Phone:

Cell:

Work:

Email:

6. Language:

Communication Ability:

effectively communicates wants/needscan carry on a conversationutilizes alternative communicationrequires a translator (specify person/agency)requires prompting/cueing to initiate conversationhas difficulty with articulation/speechrequires prompting/cueing to engage in conversation

Specify:

Comprehension Ability:

comprehends verbal directions without problemsunderstands simple directionsdoes not understand simple directionsunderstands Sign Languageother

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?

YesNo

If yes, please list below:

The applicant is currently on ProbationParole

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?

YesNo

If yes, please complete the following

Will this plan need to be utilized while the consumer receives services? YesNo

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? YesNo

If yes, how many hours per day/week are these supports provided

11. Does the applicant see a Psychiatrist and/or Counselor/Therapist?

YesNo

PsychiatristName:

Address Street:

City:

State:

Zip:

Frequency Visits:

Counselor/Therapist:

Name

Address Street

City

State

Zip

Attention/Concentration: able to stay on task independentlyeasily distractedneeds occasional verbal cues/prompts to stay on taskrequires constant cueing/prompting to stay on taskday/weekneeds prompting/cueing for orientationeasily confusednot oriented

Initiation: initiates activitiesrequests assistance when neededability varies for ADL’sneeds prompts/cues to initiate tasks/activitiescannot initiate tasks/activities

Memory: memory is functional for day-to-day activitiesshort term memory difficultieslong term memory difficulties

Organization: good organizational skillsability varies based on task/activityneeds prompting/cues for organizational skillsneeds others to provide organization

Problem-Solving/Judgment: aware of current skills/limitationsmakes reasonable decisionsneeds cues/prompts for problem-solvingunable to engage in problem-solving activities

Learning Abilities: able to follow one-step directionsable to follow multi-step directionsinterested in and willing to learn new strategies/toolsnot 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? YesNo

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 wheelchairelectric wheelchairperson to accompanyspecial accommodations

Can the applicant drive? YesNo

14. Can the applicant evacuate building during an emergency?

If no, please describe type of assistance/supports

YesNo

15. ADLS/IADLS:

Basic ADLS (Eating, Dressing, Toileting, etc.): independentneeds verbal promptingneeds physical promptingneeds hands-on assistanceneeds total support

Is this applicant continent of bladder? YesNo

Is this applicant continent of bowel? YesNo

Is this applicant able to care of feminine hygiene needs? YesNo

Will the applicant ask for toileting assistance? YesNo

Will the applicant be aware if he/she is incontinent? YesNo

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.): independentneeds verbal promptingneeds physical promptingneeds hands-on assistancemust be completed by others

IADLs (Shopping, Banking, etc.): independentneeds verbal promptingneeds physical promptingneeds hands-on assistancemust be completed by others

Endurance/Strength: able to engage in routine activitiesexperiences periodic fatiguefatigues easilyrequires frequent rest periodsneeds physical assistance to engage in routine activities

MEDICAL INFORMATION

16. Does this applicant have any known allergies?

YesNo

If yes, please list all allergies including food, medication, and environmental allergies:

Does the applicant use an Epi-Pen for any allergies? YesNo

17. Does applicant have a DNR order?

YesNo

If yes, please attach a copy

Does applicant have a Health Care Proxy?

YesNo

If yes, please attach a copy

Name of Health Care Proxy:

Name of Alternate Health Care Proxy:

Does applicant have a Living Will?

YesNo

If yes, please attach a copy

Does applicant have a Power of Attorney?

YesNo

If yes, please attach a copy

18. Has this applicant ever had a seizure?

YesNo

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? YesNo

If yes, what medication(s) is the applicant taking to control their seizures?

19. Dietary Regulations: (please check all that apply)

Swallowing Difficulties: (please check all that apply)

Aspiration precautions (please explain)

Adaptive Equipment: (please check all that apply)

Plate/BowlUtensilsCup

Dentures:

NonePartialUpperLower

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:

Other

21. Smoking:

Does the applicant smoke? YesNo

Can the applicant smoke without supervision? YesNo

Can the applicant safely keep his cigarettes/lighter on his person or in his room? YesNo

22. Durable Medical Equipment:

Supply Equipment Item

Purpose of Equipment

Prescribed by and phone number

23. Hearing Ability:

Hears adequatelyHearing difficultyUses hearing aidsUses other device

Other Device

Hearing impairment effects:

Right earLeft 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)? YesNo

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? YesNo

24. Visual Acuity:

If other, please specify

Please describe any specific information that pertains to the applicant’s vision:

Is applicant able to independently clean their glasses? YesNo

Does applicant frequently lose and/or misplace their glasses? YesNo

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? YesNo

If no, has the applicant had 1 shot for COVID? YesNo

If no, is applicant planning to be vaccinated for COVID? YesNo

Are you requesting a religious or medical exemption? YesNo

*if yes, additional forms will be sent to you for you to complete Has the applicant had COVID? YesNo

26. Medication Regimen: Please list all current medications:

Add more

Other Physician:

Add more

***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:

Cell Number:

Email Address:

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.

GENERAL INFORMATION

1. Applicant Information:

Consumer Name:

Current Address:

Phone Number:

2.In case of emergency, the following person (s) are to be called:

Current Address:

If unable to reach, call:

Current Address:

3. School/Program Information:

Address:

Contact Number:

If yes, please provide the following information:

Address:

4. Resource/Service Coordinator:

Address:

Office Contact:

5. Does applicant have a court appointed guardian or custodian?

If yes, Please list below and attach documentation:

Current Address:

6. Language:

Primary Language:

Secondary Language:

Communication Ability:

Comprehension Ability:

7. Describe the reason this applicant is requesting services from Bayside Community Network, Inc.

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)

9. Has applicant ever been convicted of a crime?

10. Does applicant have a history of behavioral challenges or a current behavior plan?

If yes, please complete the following

If yes, please attach the plan including the consents

11. Does the applicant see a Psychiatrist and/or Counselor/Therapist?

Counselor/Therapist:

12. Cognitive Status: (please check all that apply)

Orientation to:

13. Social and Recreation Activities:

Describe how the applicant interacts with the following:

Describe the applicant’s favorite hobbies/activities.

Are there special concerns when the applicant is in the community?

Does the applicant have any special travel needs:

14. Can the applicant evacuate building during an emergency?

If no, please describe type of assistance/supports

15. ADLS/IADLS:

MEDICAL INFORMATION

16. Does this applicant have any known allergies?

17. Does applicant have a DNR order?

Does applicant have a Health Care Proxy?

Does applicant have a Living Will?

Does applicant have a Power of Attorney?

18. Has this applicant ever had a seizure?

19. Dietary Regulations: (please check all that apply)

Swallowing Difficulties: (please check all that apply)

Adaptive Equipment: (please check all that apply)

Dentures:

20. Mobility:

Mode of Ambulation:

Ability to Ambulate:

Ability to Transfer:

21. Smoking:

22. Durable Medical Equipment:

23. Hearing Ability:

Hearing impairment effects:

24. Visual Acuity:

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.

26. Medication Regimen: Please list all current medications:

Other Physician:

***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:

BAYSIDE COMMUNITY NETWORK
INTAKE APPLICATION