Dominion Residence of Maryland, Inc

Dominion Residence of Maryland, Inc.

(drom, inc,)

5728 Tuxedo Road, Second Floor,

Hyattsville, MD 20781

Phone (301) 579-3638 Fax (301) 579-3306

APPLICATION FOR ADMISSION TO ADULT ALTERNATIVE LIVING UNITS (ALU)

CONTENTS

I. Information for applicant to keep:

A. Admissions and Terminations Policies and Procedures

II. Forms to be completed and returned:

A. Universal Application Single Portal Information

B. Social History

C. Pre-Admission Authorization for Release of Information

III. Additional information to be submitted before applicant can be screened for admission:

A. Psychological Evaluation (completed within the last 3 years)

B. Psychiatric Evaluation (if requested)

Return completed application packet along with psychological evaluation and, if requested, psychiatric evaluation to:

Ruth Voma, Director of Program Services

Dominion Residence of Maryland, Inc.

5728 Tuxedo Road 2nd Floor,

Hyattsville, MD 20781

For information or questions, contact Ms. Vomaat (301) 579-3638Dominion Residence of Maryland, Inc.

Application for Admission to DROM, Inc. ALU Page 2 of 18

Universal Application

Single Portal Information

I. Personal Information

Name: ______Date of Birth: ______

Address: ______Gender (M or F):______

Race: ______

Phone (Home):______

Phone (Work):______Social Sec. #:______

County of Residence: ______Financial Responsibility: ______

Contact Person: ______

Phone (Work):______Relationship: ______

Current Marital Status of Applicant: Married______Single______

Widowed______US Citizen: Yes______No______

Divorced______

II. Legal Information

Are you your own guardian? Yes______No______

Were you adjudicated incompetent by a court hearing? Yes___ No___

Effective Date______

Name of Legal Guardian: ______Telephone: Home______

Address: ______

Work______Relationship______

What type of guardianship? ______Testamentary Guardianship

______Guardian of the Person

______Guardian of Estate

______General (Plenary Guardianship)

______Partial/Limited Guardianship

Person to notify in case of emergency: Name______

Phone (Home) ______(Work) ______

Relationship______

III. Family Information

What is your relationship with your family?

Live with immediate family: ______Visit family: ______Phone Calls: ______

Live with extended family: ______No contact: ______Letters: ______

Father’s Name: ______Tel (Home) ______

Address: ______(Work) ______

Place of Employment: ______Work Hours: ______

Mother’s Name: ______Tel (Home) ______

Address: ______(Work) ______

Place of Employment: ______Work Hours: ______

Siblings: ______

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IV. Financial Information

What is your total annual income: (Employment plus benefits- check all the sources)

1. Social Security______5. SSDI______

2. Child Support______6. Veteran’s Benefits______

3. SSI______7. Employment______

4. Family______8. Other______

Check all sources:

1. Checking______4. Real Property (Value) ______

2. Trust Fund______5. Certificate of Deposit______

3. Saving______6. Other______

Financial Benefit Payee: ______Relationship:______

Financial Benefit Payee Telephone (Work):______( Home) ______

V. Applicant’s Insurance

Name of your health insurance company: ______

Policy Holder’s Name: ______

Policy #______

Group #______

Medicaid #______

Medicare#______

VI. Intellectual DISABILITY Information

Have you ever been diagnosed with any intellectualdisability ? Yes______No______

If yes, what is your primary diagnosis? ______

What is your secondary diagnosis? ______

Do you take medication for your diagnosis? Yes______No______

If yes, list by name: ______

______

______

Do you take mediations by yourself? Yes______No______

VII. Medical/Physical Information

1. Primary Diagnosis: ______

2. Secondary Diagnosis: ______

3. Other physical limitations: ______

Do you take medications? Yes______No______

Do you take medications independently? Yes______No______

Do you have any physical medications? Ambulation______Sight______Hearing______Other______

Please describe the physical limitations you checked: ______

______

______

______

______

Current Physical Illness: Type______Treatment: ______

Type______Treatment: ______

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VII. Medical/Physical Information Continued:

Have you been hospitalized in the past year for a physical condition? Yes______No______

If yes, please explain: ______

______

______

______

Is any follow-up needed: ______

Do you have allergies? Yes______No______

List to what you are allergic______

______

If someone else helped you complete this, please answer the following questions:

Name: ______Tel (Work) ______

Address: ______Tel (Home) ______

VIII. Access to Transportation

Drives own car: ______Make______Model______Licensed Plate______

Taxi______Other______

Uses public transportation______Walks______Specialized Vehicle______

Rides with others______Bike______

Do you have any problems with your current transportation? ______

DROM, Inc. Application for Admission to Adult ALU Page 5 of 18

ATTACHMENTS

A. Independent Living Skills

Indicate the level of assistance needed by circling the correct response:

1. Can do myself 2. I need to be reminded 3. I need help

Toileting 1 2 3 Household Chores1 2 3Laundry1 2 3

Grooming1 2 3 Taking Medications1 2 3GroceryShopping12 3

Dressing 1 2 3 Simple Meal Prep1 2 3Leisure Activities 1 2 3

Bathing1 2 3 Manage My Money1 2 3 Job Daily Activities1 2 3

Transportation 1 2 3 Other 1 2 3 Eating/Drinking 1 2 3

If other, please explain: ______

Is there anything else we need to know? ______

B. Education

Current school (if applicable):______Grade:______

Contact Person: ______

Telephone______

Education History

Last school attended:______Highest grade completed:______

Received High School Diploma (date):______

Received Certificate (date):______Type of Certificate: ______

Received College Degree (date):______Type of Degree: ______

Other: ______

Would you like to go to school? Yes______No______

If yes, check all that apply:

Home study______Technical Community College______

Where______

Continuing Education Courses______Where______

Two Year College______Where______

Four Year College______Where______

Other______

What classes, courses, and programs would you like to take? ______

C. Day Activity Profile

1. Do you participate in a day activity or program? Yes______No______

If yes, what type of activity or program (check all that applies):

Day Program______Where:______

Volunteer Work______Where:______

By Yourself_____ with a Group_____ with a Job Coach______

Senior service activity

program______Where______

Arts Program______Where______

Dance/Movement______

Creative Writing/Poetry______

Drawing/Painting______

Pottery______

Crafts______Describe______

Singing______

Drama______Other______

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C. Day Activity Profile Continued

2. Would you like to participate in a day activity program?

A. Would you like to attend a day program? Yes______No______

Where______

B. Would you like to do volunteer work? Yes______No______

By yourself______With a Group ______With a Job Coach______

Where:______

C. Would you like to participate in a senior service program? Yes______No______

Where:______

D. Would you like to participate in an arts program? Yes______No______

Where:______

D. Employment

Employment History:

Have you worked? Yes______No______

(Even short periods and employment during school is important)

If yes, please complete the following information:

Place of Employment Date/Length Reason for Leaving

1.______

______

2. ______

______

3. ______

______

4. ______

______

5. ______

______

What did you do at each job?

1.______

2.______

3.______

4.______

5.______

Are you currently working? Yes______No______

If yes, please complete the following information:

Name of current employer:______

How long have you been working?______

How much do you make each hour?______

Are you interested in working in the community? Yes______No______

What would you like to do?______

______

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D. Employment Continued

Will you need vocational training? Yes______No______

If yes, what kind of training do you think you will need? Please describe.______

______

______

______

What kind of other help do you think you will need?______

______

______

______

E. Residential Information

Where do you live?

With Parents______ICF/MR Group Homes______With Relatives______

With Friends______DDA ALU______Family Care Home______

Foster Care______Supervised Apt.______Alternative Family Living______

Apartment (alone)______(Roommate)______Owns Home______

Other______

Residential History

-Have you ever lived anywhere else?

Place Address Dates (To/From)

1. ______

2. ______

3. ______

4. ______

5. ______

6. ______

I am looking for a new residence because: Family Issues______

Desire a Change______

Reason______

Current residence will no longer be available______

Reason______

Other______

Reason______

Where would you like to live?

With Parents______ICF/MR Group Homes______With Relatives______

With Friends______DDA Group Home______Family Care Home______

Foster Care______Supervised Apt.______Alternative Family Living___

Apartment (alone) ______(Roommate)______Owns Home______

Other______

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E. Residential Information Continued

I prefer:

To live alone______To live with someone else close in age______

To live with others with similar interests______

To smoke in my house______

On a bus line______

To live with a non-smoker______

To live in the country______

Male staff______

To live in the city/town______

Female staff______

To have a pet______

Other______

F. Recreation & Leisure

Please list any clubs/organizations/groups in which you participate or have membership:

Name:______

Please check all that apply: ______I attend meetings ______I am a member ______I am an officer/leader

______I am a volunteer ______I attend special events ______I am not active

Name:______

Please check all that apply: ______I attend meetings ______I am a member ______I am an officer/leader

______I am a volunteer ______I attend special events ______I am not active

Name:______

Please check all that apply: ______I attend meetings ______I am a member ______I am an officer/leader

______I am a volunteer ______I attend special events ______I am not active

In my free time I like to (check all that apply):

______Spend time alone ______Read ______Travel ______Watch TV

______Listen to music ______Go Shopping______Watch/Go to Movies ______

______Write Stories ______Go to Concerts ______Visit with Friends

______Paint/Draw ______Go out on Dates ______Spend Time w/Family

______Dance ______Make Crafts ______Go out to Eat

______Sing ______Use a Computer

______Engage in Physical Fitness Activities Where:______

______Play Sports Where: ______

______Go to Church Where: ______

______Other Explain: ______

______Other Explain: ______

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G. Other Services/Support

1. Do you currently receive respite care? Yes______No______

If yes, where? In your home ______in someone else’s home______Other______

2. Do you need respite care? Yes______No______

3. Do you use any adaptive equipment/supplies? Yes______No______

If yes, please describe: ______

______

4. Do you use any augmentative communication device? Yes______No______

If yes, please describe:______

______

5. Do you use a vehicle with special adaptive devices? Yes______No______

If yes, please describe: ______

______

6. Do you need adaptive equipment/supplies? Yes______No______

If yes, please describe: ______

______

7. Do you need augmentative communication devices? Yes______No______

If yes, please describe: ______

______

8. Do you need special vehicle adaptive devices? Yes______No______

If yes, please describe: ______

______

You may use this section to tell us anything else you want us to know about yourself, what you need, what you want, what plans you have, what dreams you have:______

______

______

______

______

______

______

______

______

H. Child Development

1. Who is taking request?______

2. Source of request and phone:______

3. Date of referral:______

4. Gestation:______Weeks

5. Pediatrician:______

6. Directions to Home:______

7. Family Wants (Circle): DEC BAB DDS CSC WISH

8. Eligibility: Choose One:

______Atypical Development ______High Risk DD

______Developmental Delay ______Not Eligible

______Established Risk

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Social History

Applicant Name:______

Date:______

Mother’s Name:______

(First) (Middle) (Last) (Maiden)

A. Date of Birth:______Telephone #:______

B. Address:______

(# & Street) (City, State Zip)

Siblings (List names and ages)______

______

______

If adopted, name of adoptive family:______

At what age was applicant adopted?______

Is applicant aware of adoption?______

With whom does applicant currently live? (Including relationship to applicant)______

______

Please provide a summary of any significant information about the applicant’s early childhood, relationship with siblings, and other persons. Include any problem areas. Attach pages if necessary:______

______

______

______

______

______

______

______

______

______

______

What do you see as the applicant’s greatest need at this time?

______

______

______

______

______

DROM, Inc. Application for Admission to Adult ALU Page 11 of 18

Pre-Admission Authorization for Release of Information

Name of Applicant:______Date of Birth:______

Application for admission into a residential program operated by DROM, Inc. has been made by (or on behalf of) the above named individual.

Written permission is hereby given for this form to be copied and given to any pertinent agencies, schools, physicians, evaluation, clinics, etc. and grants permission for any and all pertinent information to be released to DROM, Inc. including but not limited to copies of the above named applicant’s social history, psychological evaluations, medical history and information, psychiatric history and evaluations and other pertinent and relevant information.

This permission is granted for the purpose of determining whether residency in the program for the developmentally disabled, operated by DROM, Inc. would be appropriate placement for the above named applicant.

I hereby give my written consent for DROM, Inc. to release any and all pertinent information regarding the above named applicant to members of the admissions committee of DROM, Inc. who will be reviewing applications for admission into said programs.

Permission is also granted for DROM, Inc. to release any and all pertinent information to representatives of the school system and/or other agencies and individuals who would be working with and/or providing services for the applicant following admission into a program operated by DROM, Inc.

Signature of Applicant:______Date Signed:______

Signature of Parent/Guardian/Representative______

Date: ______

Title (If agency representative):______

Name of Agency: ______

DROM, Inc. Application for Admission to Adult ALU Page 12 of 18

ADMISSIONS AND TERMINATIONS POLICIES AND PROCEDURES,

INCLUDING GRIEVANCE, PROCEDURESS FOR CONSUMERS

MISSION OF AGENCY

DROM, Inc. will provide quality residential services and training for persons with intellectual disability and shall consistently look for innovative resources and means for the expansion of services for this targeted disability group.

We shall also identify those individuals having the potential to move on to a less restrictive environment, and provide those persons with the necessary programming to mainstream into the community if and when possible.

TREATMENT AT TIME OF ADMISSION

Each consumer admitted to and receiving services from DROM Inc. has the right to receive age-appropriate treatment for MH/DD/SA illness or disability. Each consumer, on the first day of admission to the ALU, shall have an individual written treatment plan implemented.

ADMISSIONS CRITERIA

1. Applicants desiring admission into a program operated by Dominion Residence Of Maryland, Inc. ALU will be considered without regard to the individual's race, color, creed, religion or national origin.