SSN:
Email *
Date of Birth
Sex Male Female
Height
Weight
Birthplace
Parent/Guardian Name
Parent/Guardian Address
City, State, Zip, County
Parent/Guardian Phone Number
Parent/Guardian Work Number
Contact Person
Contact Phone Number
Diagnosis
Allergies
Is Applicant currently in a hospital or residential facility? Yes No
Discharge Date
Private Insurance Provider Name
Group #
ID#
Subscriber Name
Billing Address
Phone Number
Medicaid Number
Medicare Number
Monthly SSI/SSA Income
Child Support Payment
Father Name (First & Last)
Birthdate
SSN
Address
City, State, Zip
List Home, Work, and Cell Numbers
Employer
Occupation
Mother Name (First & Last)
Date of Birth
SSN
Address
City, State, Zip
Please list Home, Work, and Cell Numbers
Employer
Occupation
Marital Status of Parents Married Separated Divorced Widowed Never Married
Siblings (Name, Birthdate, Living at Home?)
List Others Living At Home (Name, Birthdate, Relationship)
Name of Primary Care Physician
Phone Number
Office Address
City, State, Zip
Date of Last Eye Exam
Physician Name
Phone Number
Results
Date of Last Hearing Exam
Physician
Phone Number
Results
Date of Last Swallow Study
Physician
Phone Number
Results
Are Vaccinations Current? Yes No
Received Where?
At what age was child's handicap first noticed?
Dentist Name
Address
Phone Number
Date of Last Visit
List ALL Surgeries (Type, Date, Physician, Hospital)
List All Current Medications (Name, Dosage, Purpose)
If you selected any of the above, please list the relationship of the family member.
List any allergies to medications.
Did Mother receive prenatal care? Yes No
If Yes, List Physician Name and Phone Number.
Were there any complications with pregnancy? Please Describe.
Where Was Child Born?
Was child born prematurely? Yes No
If Yes, How Early?
Birth Weight
Birth Length
Please list any other self abusive behaviors.
How are these behaviors addressed?
Does this treatment work? Yes No
When does this behavior occur?
What happens just before this behavior?
What happens just after this behavior?
What does the child do when he/she is happy?
What does the child do when he/she is sad?
What does the child do when he/she is angry?
What does the child do when he/she is frustrated?
What does the child do when he/she is tired?
How does the child communicate?
How does the child move across the room?
How does the child eat?
What kind of bed does the child sleep in?
Does the child wake often? Yes No
Does the child get out of bed?
What is the child's favorite activity?
What are your child's strengths?
What are your child's weaknesses?
Does your child concurrently receive physical therapy? Yes No
If Yes, when, where, and how often?
Single Line Text
If not, has he/she received therapy in the past? Yes No
If Yes, Where?
Are any of these items on order? If so, list the item and where is the item is one order?
Does your child currently receive Occupational Therapy? Yes No
If Yes, when, and how often?
If not has he/she received therapy in the past? Yes No
If Yes, Where?
Please select your child's skills in bathing: Independent Totally Dependent Needs Assistance
If you chose "Needs Assistance" please explain.
Please select your child's skills in toileting. Independent Totally Dependent Needs Assistance
If you chose "Needs Assistance" please explain.
Please select your child's skills in dressing. Independent Totally Dependent Needs Assistance
If you chose "Needs Assistance" please explain.
Please select your child's skills in brushing his/her teeth. Independent Totally Dependent Needs Assistance
If you chose "Needs Assistance" please explain.
Please select your child's skills in hair care. Independent Totally Dependent Needs Assistance
If you chose "Needs Assistance" please explain.
Please select your child's skills in feeding. Independent Totally Dependent Needs Assistance
If you chose "Needs Assistance" please explain.
If "Other" please explain.
Type of Liquids Regular Thickened
What Consistency?
Are foods prepared in a special way? Yes No
If Yes, How?
Are there any food allergies? Yes No
Please list any food allergies.
What foods does he/she like?
What foods does he/she dislike?
How would you rate his/her appetite? Good Fair Poor
Describe utensils (plate, bowl, cup) used to feed child.
Is child fed by bottle? Yes No
Nipple type?
What formula does child use?
Does your child currently receive speech therapy? Yes No
If Yes, Where and How Often?
If not, has he/she received speech therapy in the past? Yes No
If Yes, Where?
Does the child have a communication board? Yes No
On order with whom?
Does the child have a switch? Yes No
On order with whom?
Does the child have adaptive toys? Yes No
On order with whom?
Does your child have electronic communications device? Yes No
On order with whom?
Please list the Name and Phone Number of the school the child currently attending.
What is his/her teacher's name?
Grade Level
Please list previous school attended, grade level, and year.
Please list School District and County.
Has the child been tested by a psychologist? Yes No
If yes, what is the name of the psychologist?
Does the child have a diagnosis of intellectual disability or mental retardation? Yes No
Please include a copy of the psychological evaluation with this application.
Please provide any other important information regarding applicant's strengths and needs.