Dear Consumer/Family/Referral Agent

Dear Applicant:

Thank you for your interest in CDSMonarch. Enclosed is a packet of information about our agency and an application for services.

Please complete the enclosed application. In addition to the completed application, we will need the following information:

OPWDD Eligibility Letter

Legal Guardianship Papers

Waiver Enrollment (NOD)

Psychological (most recent)

Physical (1 year)

Social Work Evaluation (if available)

Vocational Assessments (if applicable)

DDP2 (2 year) with ISPM Score

Current Medication List/Allergies

Signed Release of Information

Diet Orders/Dining Conditions

Preliminary Person Centered Plan

Work Restrictions

Behavior Support Plan (1 year data collection, if available)

PPD/TB Test (2 step/ 2 consecutive)

ISP (Individualized Service Plan)

Level of Care Determination

IEP (Individualized Educational Program) if applicable

IPOP (Individual Protective Oversight Plan) if applicable

Interests Inventory

Photo ID

FLDDSO Community Hab Authorization Form (Comm. Hab only)

The Intake Committee will accept the most recent assessments available for the purposes of intake only. However, the agency requires more current assessments before placement in any CDSMonarch program.

Once you have gathered this information, please fax to 585-347-1234 ormail to:

Francesca Wetmore-Rivera, Intake and Guardianship Coordinator
CDS Monarch
860 Hard Rd.

Webster, NY 14580

Once received, we will review the application and contact you. An efficient intake process is the goal of CDS and we look forward to providing you with quality services. If you have any questions, please contact me at (585) 347-1227or via email at . Again, thanks for your interest in our agency.

Sincerely,

Francesca Wetmore-Rivera,

Intake and Guardianship Coordinator

Mission
CDS Monarch is an organization of highly-skilled, dedicated people that that offers quality opportunities and services to individuals for their well being and growth.

Vision
CDS Monarch is a world-class organization that supports people in pursuit of their personal dreams.

Individual’s Name: ______

SUPPORTS REQUESTED(Check all that apply):

Housing (i.e. family Care, ISS Contracts, IRA’s, Community Living)

Employment

Medicaid Service Coordination

Recreation/Respite (age 5 – adult)

Parent Support Group

Autism Skill Building Program (6-16)

Sibling Support Group (school age)

Community Habilitation

Consolidated Supports & Services (CSS)

Day Habilitation

Senior Living

Waiver Enrolled: Yes NoNOD date:______

(NYCARES) New York State Cares Enrolled: Yes No

Service Coordinator: ______

Agency: ______Phone #:______

Address: ______

Email: ______Fax #: ______

School District (if applicable): ______

Contact Name: ______Phone #: ______

Email: ______Fax #: ______

Have you ever received CDS Monarch services in the past? Yes No

How did the individual/family find out about CDS Monarch? Self Family Friend Website

Agency ______

Other: ______

URGENCY OF NEED: ImmediateWithin 1 yearAfter 1 year

Completed by: ______Phone #: ______Email: ______

Individual’s Name: ______Sex: MaleFemale

Address:______Type of Residence: ______

______

Phone:______Birth date: ______

Social Security #: ______Medicaid #: ______

Benefits:SSISSDPublic AssistanceFood Stamps # ______

Life InsuranceTrust Fund Burial Fund Tabs #: ______

Medicare #: ______Medicare Part D Carrier: ______

Spend Down (please describe): ______

Pay Back (please describe): ______

Representative Payee: ______

Disabilities:Mental RetardationLearning DisabilityCerebral Palsy

AutismNeurological ImpairmentEpilepsy (type): ______

Other (specify): ______

Medication (list and dosage): ______

______

GUARDIANSHIP / CORRESPONDENTS:

Legal Guardian: ______Date Established: ______ Not Established

Family/Advocate Contact:Relationship:

Address: Phone:

Email:

Alternate Contact:Relationship:

Address:Phone:

Email:

Day Program: Contact:

Address:Phone:

RESIDENTIALCASE MANAGEMENTFAMILY SUPPORT

Community Residence Medicaid Service Coordination Autism Family Support

ICF TBI (Traumatic Brain Injury)HCBS Waiver

IRA (Group Home) PCSS (Plan of Care Support Services)Parent Support Group

Supervised ApartmentResidential Habilitation (Community)

Supportive ApartmentRecreation (Ages 5 to Adult)

Family CareOther: ______

DAY SERVICESCLINICAL SERVICES

Day Treatment Individual Placement Social Work Counseling

Day HabilitationSupported Enclaves Occupational Therapy Speech Therapy

Sheltered WorkshopSchool Physical Therapy Nursing Services

Prevoc. Services Transition Program Services Psychiatry/Psychology

Other ______

LEVEL OF SUPERVISION NEEDED:(Please indicate whether the Individual needs: total support, assistance, supervision or is independent for the following skills)

Food Prep: House Keeping: Toileting: Fire Evacuation:

Cooking: Laundry: Dressing: Community Safety Skills:

Eating: Phone Usage: Grooming:

Shopping: Money Management: Bathing:

TRANSPORTATION: (Check all that apply)

Able to Use Lift Line Has Drivers License (No Car)

Has Own CarNeeds Transportation

Able to Use RTSCan Take a Taxi

Potential for Travel Training School Buswithaide

MOBILITY STATUS: (Check all that apply)

Ambulatory Uses manual wheelchair Able to negotiate stairs

Requires use of lift One-person transfer Several person transfer

Able to bear weight Can be transported in a car Requires vehicle with lift*

*Braun Lift: 34 wide/ 54 long – 800 to 1000 pounds total individual + wheelchair weight capacity

COMMUNICATION:

Primary Language: ______Requires an Interpreter Yes No

Verbal Yes No Uses sign language Yes No

BEHAVIOR SUPPORT PLAN OR GUIDELINES: Yes (If yes, please attach behavior support plan & date collection for past year) No

Even if no, please describe any behaviors, safe guards or special needs:______

Application Prepared By

Name: Title:Date:

I,______hereby authorize the release of information to CDS Monarch and the Central Entry Committee.

The purpose of this disclosure is referral for CDS services. I understand that this authorization covers only the information listed below and that CDS/Central Entry Committee and all of the participating agencies will maintain the confidentiality of this information. CDS, the Central Entry Committee, and all participating agencies will not release this information.

Information to be released: (Please attach all documents) / Date of Form/Assessment / Attached

OPWDD Eligibility Letter

Legal Guardianship Papers

Waiver Enrollment (NOD)

Psychological (most recent)

Physical (1 year)

Social Work Evaluation (if available)

Vocational Assessments (if applicable)

DDP2 (2 year) with ISPM Score

Current Medication List / Allergies

Release of Information

Work Restrictions

Behavior Support Plan (1 year data collection, if available)

IPOP (Individual Protective Oversight Plan) if applicable

PPD/TB test (2 step/ 2 consecutive)

ISP (Individualized Service Plan)

IEP ( Individualized Education Program)if applicable

Level 1 Assessment/Transition Plan, if applicable

Photo of Applicant (if available)

LCED

FLDDSO Community Hab Authorization Form (Comm. Hab only)

Preliminary Person Centered Plan

Interests Inventory

______

Applicant’s SignatureAdvocate/Legal Guardian Signature

______

DateDate

______

Relationship to Applicant

NOTE: THIS CONSENT MAY BE REVOKED AT ANY TIME BY PUTTING SUCH

REQUEST IN WRITING AND SUBMITTING TO THE INTAKE/GUARDIANSHIP COORDINATOR.

Francesca Wetmore-Rivera, Intake and Guardianship Coordinator

860 Hard Rd.

Webster, New York 14580

Phone: (585) 347-1227Fax: (585) 347-1234

Preliminary Person Centered Plan

Self-Advocacy

Name: ______Self-Advocates Independently

Self-Advocates with Supervision or Assistance

Advocate (if Appropriate):______Requires Total Assistance with Advocating

Information Regarding Applicant: Diagnosis, Functioning Ability, etc.;

______

Current Services

What current services are working for you?

______

What services are not working for you?

______

Are there any health and/or safety concerns that need to be addressed?

______

What services have been explored and have not met the individual’s needs?

______

Person completing this form: ______

Relationship and Contact Information: ______

Person Centered Planning

To be completed by Individual and/or Advocate.

How would you describe ______?

Name

______

Who is in ______’s circle of support? (non-paid, natural supports)

Name

______

What must ______have to be happy?

Name

______

What has helped ______to grow and develop?

Name

______

What are ______‘s personal obstacles?

Name

______

What is it that ______would like to accomplish?

Name

______

How do you believe that CDS Monarch can assist in completing your goals?

______

Interests Inventory

Individual Name: Date:

Indicate which interests are maintained by the person. When known, please provide any additional details (Example: Animals = Dogs, Horses, etc)

Animals:

Art:

Being Alone:

Books:

Bowling:

Carnivals:

Cars:

Celebrations:

Challenges:

Children:

Church:

Cleaning:

Collecting Things:

Community Outings:

Computers:

Concerts:

Cooking:

Crafts:

Crowds:

Dancing:

Doctors:

Drawing:

Electronics:

Fishing:

Foods:

Games:

Gardening:

Helping Others:

Housework:

Magazines:

Money:

Movies:

Museums:

Music:

Outside (being):

People:

Photographs:

Photography:

Praise:

Recognition:

Responsibilities:

Restaurants:

Rides:

Sewing:

Shopping:

Singing:

Skating:

Sleeping:

Smoking:

Socializing:

Sports:

Swimming:

Talking:

Television:

Theatre:

Traveling:

Vacations:

Variety:

Visiting Others:

Volunteering:

Walking:

Work:

Writing:

Yard work:

Zoo:

Other Activities Not Listed: ______

______

Completed by:

Name / Title

How did you hear about us? (Check all that apply)

Family Member of Friend

Service Coordinator

CDS Monarch Employee

Community Event (please specify) ______

Job Search Site (i.e. Careerbuilder, Indeed)

Search Engine (i.e. Google, Bing, Yahoo)

Social Media

Radio

Other: (please specify) ______

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