New Member Inquiry
Date
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Month
-
Day
Year
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Applicant Information
Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
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Age
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Applicant lives with:
I am interested in
Weekday programs
Dances
Parent/Guardian Information
Parent/Caregiver #1
First Name
Last Name
Parent/Caregiver #2:
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Cell Phone Number
-
Area Code
Phone Number
E-mail
*
Relationship to applicant
Parent
Sibling
Other Relative
Guardian
Does the applicant have a legally appointed Guardian?
Yes
No
If yes, who is the legal Guardian?
Did the applicant complete a high school or specialized training program?
Yes
No
Unsure
Please list the state, school name, and year of completion
Applicant's health information
Medical Diagnosis
Explanation of applicant's current health condition
Does the applicant have any allergies:
Yes
No
List all allergies and reactions
Does the applicant have food restrictions?
Yes
No
Please explain food restrictions
Explain any special needs of the applicant
Physician
Personal care
Mobility:
Ambulatory
In a wheel chair
Uses a self-propelled wheelchair
Uses an assistance scooter
Feeding:
*Independently feeds self
*Needs assistance with feeding
*Uses a feeding tube
*Needs thickened liquids
*Cannot have liquids
Bathroom:
Toilets independently
Needs assistance while toileting
Requires supervision while toileting
Group Setting:
*Independently manages in a group setting
*Needs extra supervision in a group setting
*Requires 1-1 assistance in a group setting
Physical concerns
choking
falling
seizure
Elopement (leaving an area without permission)
General information
Has the applicant ever responded aggressively toward a family member, a peer, or caregiver?
Yes
No
Please explain
Please list behavioral concerns or tenancies
Have you ever had any incidents requiring the response of law enforcement
Yes
No
Please explain
Does the applicant receive Med Waiver/HCBS?
Yes
No
Do you utilize the CDC+ program?
Yes
No
If accepted to the program, does the applicant have transportation?
Yes
No
How did you first hear about Transitions Life Center?
*
I understand the THRIVE program comes with a fee of $50 per day. TLC is an approved CDC+ vendor and individuals who are covered under Consumer Directed Care are eligible to utilize their budget to cover TLC expenses.
*
I have answered all information correctly. False or incomplete information may result in dismissal from program after an individual has been accepted.
Administrative Notes
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