"Achieving Full Community Life For Children And Adults With Intellectual And Developmental Disabilities - One Person At A Time

"Achieving full community life for children and adults with intellectual and developmental disabilities- one person at a time

To: Respite Family

From: Karen Dotson

Subject: DHR Respite Application

Enclosed please find an application for DHR Respite Funds. Please be sure to complete the following forms:

●  The Arc of Howard County Application for DHR Respite Funds

●  Documentation of Developmental Disability

Please send a copy of one of the following:

1.  Physical Exam or

2.  Psychological Documentation or

3.  Professional Report that lists the diagnosis

●  Income Eligibility Form

Please send copies of the following:

1.  Copy of Award Letter from Social Security stating amount of benefits and/or

2.  Copy of Pay Stubs for 1 month

3.  Copies of valid medical receipts

●  Authorization to Release/Obtain Information

●  Signed Informed Consent Form

Once we receive the application and forms, we will send you a letter notifying you of the status of your application and the process for accessing DHR Respite Funds.

"Achieving full community life for children and adults with intellectual and developmental disabilities - one person at a time."

The Arc of Howard County, Inc.

Application for DHR Funds

(Please Print or Type)

Date of Application: ______

APPLICANT’S GENERAL INFORMATION

Name:______

Last First Middle

Date of Birth: ___/___/___ Place of Birth: ______

Current Address: ______

Street City State Zip # of years

Permanent Address: ______

Street City State Zip # of years

Telephone #: ______County of Residence: ______

Social Security #: ______Type of Income/Amount: ______

Medicare #: ______Medical Assistance #: ______

Other Health Insurance: ______Prescription Coverage: ______

Does Applicant have a Service Coordinator? ______

Name Phone #

PARENT/GUARDIAN/CAREGIVER INFORMATION

Name: ______

Address: ______

City/State: ______

Phone: ______ Relationship to Applicant: ______

11735 Homewood Road, Ellicott City, MD, 21042 | 410-730-0638 | 410-995-1644 | 301-596-4991

FAX: 410-730-0730 | www.archoward.org | TTY: 1-800-735-2258

APPLICANT’S LIVING SITUATION/ FAMILY SITUATION – Please Include Names

Parents: ______Guardian or Relatives: ______

Foster Home: ______Other: ______

Address: ______

Phone Number: ______Legal Guardian: ______

Date Guardianship Was Attained: ______

Type of Guardianship (Check whichever applies)

Full Property Limited Medical Person

FAMILY INFORMATION
FATHER / MOTHER
Name: / Name:
Birth Date: / Birth Date:
Address: / Address:
Home Phone: / Home Phone:
Occupation: / Occupation:
Work Phone: / Work Phone:
Work Address: / Work Address:
Social Security #: / Social Security #:
Living/Deceased
If deceased, date: / Living/Deceased
If deceased, date:
Place of Birth: / Place of Birth:
Marital Status: / Marital Status:

BROTHERS AND SISTERS (Use additional paper if necessary):

NAME / BIRTH DATE / PHONE # / ADDRESS / OCCUPATION
EMERGENCY CONTACT: (Other than Parent/Guardian/Caregiver)

Name: ______Relationship to Applicant: ______

Address: ______Phone: ______

APPLICANT’S FINANCIAL INFORMATION

SSI Claim #: ______SSI Amount: ______

SSA Clam #: ______SSA Amount: ______

Name of Wage Earner: ______

Name of Representative Payee:______

V.A. Claim #: ______V.A. Benefit Amount: ______

Name of Veteran: ______

Railroad Retirement Claim Number: ______

Name of Wage Earner: ______Life Insurance Coverage: ______

Burial Plot Location: ______

Estimated Value: ______Type of Burial Plan: ______

Other Sources of Applicant’s Income: ______

Applicant’s Bank Account: ______Bank Name: ______

Any Property in Applicant’s Name (Give Location and Value): ______

Trust Fund: YES NO Type: ______

If Yes, Give Name and Address of Trustee: ______

Applicant’s Place of Employment (Name and Address): ______

Applicant’s Monthly Earnings from Employment: ______

MEDICAL INFORMATION

A. Applicant’s Primary Health Care Provider/Physician: ______

Address: ______Phone: ______

Date of Last Physical Exam: ______Examined By: ______

Address: ______

Hospital Familiar with Applicant (if any): ______

B. Diagnosis:

Primary: ______

Secondary: ______

Tertiary: ______

Age of Onset: ______

C. LIST ANY MEDICATION(S) TAKEN BY APPLICANT

MEDICATION / DOSAGE / REASON

D. HISTORY OF HOSPITALIZATIONS

DATE / REASON / HOSPITAL / PHYSICIAN

E. SEIZURES

1. Does the applicant have seizures? Yes No

2. Frequency: Daily Weekly At Least Once A Month Every Few Months

3. Type of Seizure: ______

4. Are seizures controlled by medication? Yes No

F. APPLICANT’S MOBILITY

Walks Independently Uses Cane Uses Crutches Uses Walker

Uses Wheelchair Manual Electric

G. VISION

1. Any Vision Impairment? Yes No

2. Does Applicant wear glasses or contact lenses? Yes No

3. Date of Last Eye Exam: ______Legally Blind? Yes No

H. HEARING

1. Does Applicant have a hearing problem? Yes No

2. Does Applicant wear a hearing aid? Yes No

3. Date of Last Hearing Exam: ______Deaf? Yes No

I. DENTAL

1. Date of Last Dental Exam: ______Dentures? Yes No

2. Brief Description of Any Dental Problem: ______

SPEECH AND LANGUAGE INFORMATION

1. Does applicant have speech/language impairment? Yes No

2. Is Applicant Verbal? Yes No

3. Has applicant had speech/language assessment? Yes No

4. Assessment Done By: ______

5. Means of Communication:

Speech Sign Language Gestures Communication Board

Other: ______

J. ALLERGIES (bee stings, drugs, dust, mold, food, etc.)

______

______

Does applicant have any other medical problems not listed above?

______

______

______

MENTAL HEALTH

1. Does applicant have a history of mental health, alcohol, or substance abuse? Yes No

List Previous Treatments and Dates:

DATE / TREATMENT CENTER / IN PATIENT OR OUT PATIENT / PHYSICIAN/COUNSELOR

2. Is the applicant currently in treatment? Yes No

3. Name of psychiatrist/counselor: ______

4. Diagnosis: ______

PSYCHOLOGICAL INFORMATION

A. Date of Last Psychological Evaluation: ______

Performed by: ______

Address: ______

Diagnosis: ______

B. DOES APPLICANT HAVE A HISTORY OF BEHAVIORAL PROBLEMS? YES NO

(If so, describe the problem using the chart below.)

BEHAVIOR / FREQUENCY / SEVERITY / INTERVENTION

C. HAS THE APPLICANT EVER BEEN CONVICTED OF A CRIME? YES NO

PROVIDE DETAILS: ______

______

______

D. IS ANY OTHER FAMLY MEMBER DIAGNOSED AS HAVING A DISABILITY?

DESCRIBE: ______

BACKROUND INFORMATION
NAME OF SCHOOLS ATTENDED / COMPLETE ADDRESS / DATE

CONTACT PERSON: ______

ADULT PROGRAMS ATTENDED / COMPLETE ADDRESS / DATE

CONTACT PERSON: ______

VOCATIONAL TRAININGS OR EVALUATION / COMPLETE ADDRESS / DATE

CONTACT PERSON: ______

SKILLS CHECKLIST

A. Is applicant dependent in personal self-care skills? YES NO

B. Can applicant self medicate? YES NO

C. Can applicant cross streets? Independently With Assistance NO

D. Can applicant use mass transit? Independently With Assistance NO

E. Is applicant capable of remaining at home unsupervised?

YES NO How Long? ______

F. Can applicant read? YES NO What Level? ______

G. Does applicant sleep through the night? YES NO

H. What time does the applicant usually go to bed? ______

I. What time does the applicant get up in the morning? ______

J. What does the applicant like to do in his/her free time? ______

______

______

______

______

SIGNATURES

______

SIGNATURE OF PARENT/GUARDIAN (IF APPLICABLE) DATE

______

SIGNATURE OF PARENT/GUARDIAN (IF APPLICABLE) DATE

______

SIGNATURE OF PARENT/GUARDIAN (IF APPLICABLE) DATE

The Arc of Howard County, Inc. provides services and operates its programs without discrimination on the basis of race, color, national origin, religion, political affiliation, marital status, age, sex or disability. The following information is useful for statistical purposed only; completion of this portion of the application is voluntary.

Religion: ______

Ethnic Identification (check as applicable):

African American Caucasian Hispanic Asian

Other: ______

U.S. Citizen: Yes No Sex: Male Female

Language (s) used in Applicant’s home environment:

English Other, specify: ______

"Achieving full community life for children and adults with intellectual and developmental disabilities - one person at a time."

The Arc of Howard County, Inc.

DHR Respite Funds Income Eligibility Form

Parent’s Caregivers Gross Income:

If the individual to be cared for is under age 18, please list income of family including

the individual. List by sources and whether income is weekly, monthly or annually.

Number of Individuals Living In the Home: ______

NAME / TOTAL INCOME / WEEKLY / MONTHLY / ANNUALLY / SOURCE
1.
2.
3.
4.

Applicant’s Gross Income:

If the individual to be cared for is age 18 or above, please list the income of the

individual and the person’s spouse, if married.

NAME / TOTAL INCOME / WEEKLY / MONTHLY / ANNUALLY / SOURCE
1.
2.
3.
4.

Foster Care: If the individual lives in a foster care home, write the name, the foster care

agency, case worker, and telephone number.

NAME / AGENCY / CASEWORKER / PHONE NUMBER/EXT.
1.
2.
3.

11735 Homewood Road, Ellicott City, MD, 21042 | 410-730-0638 | 410-995-1644 | 301-596-4991

FAX: 410-730-0730 | www.archoward.org | TTY: 1-800-735-2258

Medical Expenses may be deducted from total income if the medical expenses are:

1) Related exclusively to the expenses of the individual with the

developmental disabilities.

2) Documented as paid by a valid receipt.

3) Not covered by any insurance or other payment coverage.

4) Calculated for the preceding 12 months.

I certify that the above information is accurate:

______

Signature of Applicant Date

** Please attach a copy of your most recent pay stub and/or a copy of the Social Security Letter stating the amount of the benefit payment and copies of any valid medical receipts.

"Achieving full community life for children and adults with intellectual and developmental disabilities- one person at a time."

AUTHORIZATION TO RELEASE/OBTAIN INFORMATION

DHR Respite Funds

Date: ______

Name of person with developmental disability: ______D.O.B. ______

Address:

______

______

I, ______, hereby authorize ______

Doctor’s Name, Clinic/Hospital Name or other

professional/ agency

______

Address with Zip Code

______

______

Phone Number

to release medical, psychological, social narrative and other pertinent information to The Arc of Howard County, Inc. as presently requested by same.

Authorization is extended for this request only and at this time only.

I understand that the information is requested for the purposed of assisting The Arc of Howard County, Inc. in serving me now and/or planning with me for the future.

I understand that all the information will be treated in a strictly confidential manner.

______

Signature Date

______

Parent/Guardian (must sign if client is under 18) Date

______

Witness (must sign if “X” is used) Date

______Agency Representative Date

11735 Homewood Road, Ellicott City, MD, 21042 | 410-730-0638 | 410-995-1644 | 301-596-4991

"Achieving full community life for children and adults with intellectual and developmental disabilities - one person at a time."

INFORMED CONSENT

I fully recognize and understand that the relationship between myself and the provider is a private relationship. I release The Arc of Howard County, Inc. of responsibility/liability for any actions of this provider. By my signature/mark below, I also recognize that the relationship between The Arc of Howard County, Inc. and myself is only that of a resource DHR Respite Funds and I will make payment directly to the respite provider.

______

Parent/Guardian’s Signature Date

If the individual requesting services is over 18 years of age, he/she must sign name or mark, and be witnessed unless a legal guardian has been appointed.

______

Parent/Guardian’s Signature Date

______

Witness’ Signature Date

11735 Homewood Road, Ellicott City, MD, 21042 | 410-730-0638 | 410-995-1644 | 301-596-4991

FAX: 410-730-0730 | www.archoward.org | TTY: 1-800-735-2258