Have you been determined DDA eligible?

YesNo

DDA Waiver Approved?

YesNo

Select all that apply:

Day HabilitationEmployment ServicesCommunity Development ServicesCareer Exploration: Facility-based

*LSE is no longer a Sheltered Workshop

Name (Last, First, Middle)

Street Address

City

State

Zip

Home Phone

Cell Phone

Date of Birth

Sex

—Please choose an option—FemaleMaleNon-binaryPrefer not to say

SS# (optional)

Primary Disability

Secondary Disability

Did the individual receive 1:1 support?

YesNo

If yes, what was the purpose of the support?

Was the individual in a self-contained or general education classroom?

Who does the individual live with? (select all that apply)

ParentsMotherFatherRelativeAgencySelfOther

If other, please specify

Primary Caregiver’s Name

Primary Caregiver’s Phone

Primary Caregiver’s Email

Legal Guardian Name

Legal Guardian Phone

Legal Guardian Address (if different)

Legal Guardian Email

Upload guardianship paperwork (PDF/Image)

Emergency Contact 1 – Name

Emergency Contact 1 – Address

Emergency Contact 1 – Phone

Emergency Contact 1 – Cell

Emergency Contact 1 – Relationship

Emergency Contact 2 – Name

Emergency Contact 2 – Address

Emergency Contact 2 – Phone

Emergency Contact 2 – Cell

Emergency Contact 2 – Relationship

If applicable, list program name, contact person, and phone.

Agency 1 – Program Name

Agency 1 – Contact Person

Agency 1 – Phone

Agency 2 – Program Name

Agency 2 – Contact Person

Agency 2 – Phone

Agency 3 – Program Name

Agency 3 – Contact Person

Agency 3 – Phone

Is transportation needed?

YesNo

Can the individual use public transportation?

YesNo

Does the individual use a wheelchair?

YesNo

Special accommodations

Is the individual currently employed?

YesNo

If yes, where?

If no, are you interested in Community Employment?

YesNo

Select all that apply:

Communicates in full sentencesUses sign languageFollows simple verbal commandsAble to follow simple written directionsUses a communication device

Describe any assistance needed

Eating habits

IndependentRequires assistance with set up/heating meals

Describe any assistance needed

Select all that apply:

IndependentContinentPeriodic incontinenceRequires reminders or toileting scheduleRequires prompting – hygieneRequires assistance with transfersRequires full assistanceUses adult incontinence pads or underwear

If a toileting accident happens, what assistance is needed?

Select all that apply:

Walks independentlyUses caneUses walkerNeeds assistance when walkingNeeds assistance with transfersUses wheelchair at timesUses a wheelchair at all timesUses a scooter

Describe any assistance needed

Is the individual social?

Does he/she smoke or use drugs?

Are there any strong fears we should be aware of?

Please describe the individual’s personality traits

Is there a current Behavior Plan?

YesNo

Has the individual had a Behavior Plan in the last 3 years?

YesNo

Upload Behavior Plan (if applicable)

If there is no Behavior Plan: Is there any negative behavior staff should be aware of?

If yes, what strategies are effective?

Other Medical Diagnosis

Food or Medication Allergies (list)

Current Weight (lbs)

Special Diet

Medication Administration

Self-administersNeeds promptingCannot self medicate

Current medications can be listed below or attached as a document.

Current Medications (list / notes)

Attach medication list (optional)

Any history of seizures?

YesNo

Do seizures last longer than 5 minutes?

Describe seizures

List equipment and when used (helmet, splints, communication devices, AFO, etc.)

Adaptive equipment details

Any old scars, bumps or lumpsHistory of Sinus InfectionsHistory of nose bleedsDifficulty chewing or swallowingUse of dentures or bridgesHistory of eye problemsUse of corrective lenses (glasses)Uses of contact lensesHistory of cataracts or glaucomaAbnormal sensitivity to lightAbnormal sensitivity to soundHistory of ear infectionsUses hearing aid (Left)Uses hearing aid (Right)History of pneumonia or bronchitisDifficulty breathing (asthma, COPD, wheezing)History of stomach ulcers, vomiting bloodHistory of RefluxHistory of constipation or diarrheaHistory of urinary tract infectionsIncontinenceHistory of fainting or loss of consciousnessHistory of cognitive disturbancesHistory of speech or language dysfunctionHistory of fracturesSpinal deformityChronic back problemsHistory of anemiaHistory of easy bruisingAny open sores, wounds or rashes on bodyHeat or cold intolerance

Other pertinent information

Signature of applicant (type full name)

Signature of person completing form (type full name)

Signature of legal guardian (type full name)

Date

Your Email (for confirmation copy)