Application for Students Transitioning to Adult Services

Date of Application

Application for Students Transitioning to Adult Services

Instructions: Completion of this form is the first step in applying for adult services. It is recommended that you complete and keep the original, and make copies for the providers to which you want to apply. Though additional documentation may be requested, the following service providers have agreed to accept this universal application:

Arc Prince George’s Co
Ardmore Enterprises
CHI Centers
Compass
EBED
EPIC / Family Services Foundation
Full Citizenship of Maryland
Maryland Community Connection
Maryland Neighborly Network
MedSource Community Services
Melwood HTC / New Horizons Support Services
SEEC
Social Health Services Group
Sunrise/UCP on the Potomac
VOCA/ResCare

Applicant Information

Full Name

Phone#Social Security# Date of Birth

Current Address

Permanent Address

Ethnic Identification (optional):

African AmericanAsianCaucasianLatinoNative AmericanOther:

Gender:MaleFemaleU.S. Citizen:YesNo

Height’”Weight lbsEye Color Hair Color

Language(s) spoken or understood:EnglishOther:

Language(s) spoken in applicant's home:EnglishOther:

Guardian/Caregiver Information

NameRelationship to Applicant

Living Situation/Support:FamilyFoster HomeLegal Guardian of Adult*

*Type of Guardianship:PersonPropertyMedicalLimited Power of Attorney

Date and County of Adjudication

Address(preferred contact below)

Phone #’s:HomeCell Work

EmailBest time to reach you

Emergency Contacts(use additional paper if necessary)

NameRelationship to Applicant

Address(preferred contact below)

Phone #’s:HomeCell Work

Email

NameRelationship to Applicant

Address(preferred contact below)

Phone #’s:HomeCell Work

Email

Family Information

Parent Information / Father / Mother
Name
Address
Home Phone
Cell Phone
Business Phone
Date of Birth
If deceased, date of death
Siblings/Other Family Members Living in the Household (use additional paper if necessary)
Name
Relationship to Applicant
Phone
Date of Birth

Medical Information

A.Diagnoses:

Primary Disability

Additional Diagnosis

B.Medications (use additional paper if necessary)

Medication / Dosage & Frequency / Purpose

C.Insurance Information:

Applicant’s Medicare#Type

Other Medical Insurance (company policy#)

D.Healthcare Provider Information:

Primary Care PhysicianPhone#

Address

Preferred Hospital

DentistPhone#

Dentures or other prosthetic?NoYes:

SpecialistPhone#

SpecialistPhone#

SpecialistPhone#

E.General Health Information -(check all that apply):

Vision impairmentLegally BlindGlassesContact Lenses

Hearing impairmentDeafHearing Aid

Seizure disorder (type)Controlled with medication: Yes No

Speech or language impairment

Means of communication:SpeechSign/ASLGesturesPicture/Symbol Device

Speech/language assessment byDate N/A

Does the applicant have(check all that apply and explain below):

other medical conditions not listed above?

a history of significant surgeries or hospitalizations?

a special diet; use adaptive dishes/utensils; or need feeding assistance?

any allergies (environmental, medication, foods, etc.)?

Mental Health/Psychological

Most recent psychological exam by Date N/A

Does the applicant have a history of behavioral concerns?YesNo

Does the applicant have a current behavior plan in school?YesNo

If yes to either of the above, please briefly explain below (use additional paper if necessary):

Education

Schools and/or Adult Programs Attended (use additional paper if necessary)

Name / Address / Dates Attended

Skills, Safety, and Support Needs

A.Mobility (check all that apply):

Walks IndependentlyUses Assistive Device(s): Canes or CrutchesWalkerWheelchair

Wheelchair typeTransfers:Independently With assistance

Community/Pedestrian Safety:

Able to cross streets:IndependentlyWith assistanceNot at this time

Uses mass transit:IndependentlyWith assistanceNot at this time

Uses Paratransit/Metro Access:IndependentlyWith assistanceNot at this time

Metro Access eligibility/ID card:YesNo

B.Activities of Daily Living:

Independent in personal self-care (e.g. hygiene, eating, toileting)YesSomewhatNo

If applicable, level of assistance needed:verbal promptstand-by supportfully assist

Is able to independently self-medicate:YesNo

Is capable of remaining home unsupervised:YesNoIf Yes, for hours

C.Routines:

Usually sleeps through the night:YesNo

Usually goes to bed at (time) and gets up at

Provide a brief description of daily routine:

D.Skills and Interests:

Reads:NoYes - level:Writes:No Yes - level:

Hobbies/Interests:

Other:

Employment

Is the applicant currently employed?NoYes - Provide employment information below:

EmployerPhone#

Address

Supervisor's NamePhone#

Job TitleStart date Wage $

Duties

Previous Employment (use additional paper if necessary):

Company Name / Address / Phone#
Job Title / Supervisor’s Name / Dates Employed
Company Name / Address / Phone#
Job Title / Supervisor’s Name / Dates Employed
Company Name / Address / Phone#
Job Title / Supervisor’s Name / Dates Employed

If applicant is not currently employed, what are his/her job interests?

Financial Information (Complete only if seeking residential services)

SSI Claim#SSI Amount$ SSA Claim# SSA Amount $

Representative payee/relationship to applicant

Other Applicant Income

BankAccount Types:CheckingSavings Other:

Trust Fund:NoYes - Type

Name and address of trustee

Assets in applicant's name (location value)

Additional Team Members

Does applicant have a Coordinator of Community Services (CCS)?YesNo

If yes, name and phone#

Does applicant have a DORS Counselor?YesNo

If yes, name and phone#

Does the applicant have a Social Worker?YesNo

If yes, name and phone#

Indicate current services or financial assistance and provider:

Respite:In-Home Supports: LISS:

Foster Care:REM: CFC:

Other:

Signatures

Signature of Applicant (if over 18 year old)Date

Signature of parent/guardian (if applicable)Date

Signature of Person Completing FormDate

Office Use Only

Application receivedCategory:Crisis ResolutionCrisis Prevention Current Request/TY

Authorized for:

Supported EmploymentEmployment Discovery & CustomizationCommunity Learning Services

Day HabilitationSelf-Directed Services

Residential HabilitationPersonal Support ServicesShared Living

Comments/Notes:

Page 1 of 6