New Member Inquiry
Date
*
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Month
-
Day
Year
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Applicant Information
Name
*
First Name
Last Name
Birth Date
*
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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 my member attending
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1 Day a week
2 Days a week
3 Days a week
4 Days a week
5 Days a week
Parent/Guardian Information
Parent/Caregiver
*
First Name
Last Name
Primary Phone Number
*
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Area Code
Phone Number
Secondary Phone Number
*
-
Area Code
Phone Number
E-mail
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship to applicant
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Parent
Sibling
Other Relative
Guardian
Other
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/ disability Diagnosis.
*
Explanation of applicant's current health condition.
Does the applicant have any allergies?
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Yes
No
does the applicant independently understand his or her allergies?
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Yes
No
List all allergies and reactions
*
Does the applicant have food restrictions?
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Yes
No
Please explain food restrictions and any important information regarding food restrictions.
Explain any special needs of the applicant
*
Physician
*
Personal care
Mobility:
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Walks independently.
Walks independently with assistive device (walker).
Walks with supervision.
Walks with assistance.
Uses a self-propelled wheelchair.
Uses a wheelchair and needs assistance.
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
Requires prompts to go to the bathroom
Requires assistance only with bowel movement
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)
Other
General information
Has the applicant ever responded aggressively toward a family member, a peer, or caregiver?
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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
Interested in Marion Transit bus service
How did you first hear about Transitions Life Center?
*
*
I understand the THRIVE program comes with a fee of $50 and/or $55 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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