AutismServices Association, Inc.
47 Walnut Street, Wellesley Hills, MA 02481
TEL: (781)237-0272Fax: (781)237-5020
E-Mail:
Website:
PROGRAMAPPLICATION
DATE OFAPPLICATION
I. Applicant’s Name
Date ofBirth
Address
Social Security#
Phone#
Applicant’s Mass. Health # (If applicable)
II. Parent(S) Name
(H)Phone#
Address
(W) Phone#
III. Guardian’s Name _(H)Phone
Address
(W) Phone#
IV. DMR ServiceCoordinator/ RehabCouncilororSchool DistrictRepresentative:
Name
Phone#
Address
V. Applicant’s Current Program
Contact Person
VI. FunctionalLimitations
VII. Attacha copy ofapplicant’s current IndividualSupport Plan(ISP) orIndividual
EducationPlan(IEP).
VIII. Attacha copy ofapplicant’s most recentmedical, psychological, educational,
vocational, andspeech/language evaluations.
Return completedApplicationto:ProgramDirector,AutismServicesAssociationInc.,
47 Walnut St.
Wellesley Hills, Ma. 02481
Autism ServicesAssociation
ReferralCheck list
Participant:
ProjectDirector:
Date:
YES / NODATEOF TOUR
PROGRAMAPPLICATION
INTAKEINTERVIEW
ACCEPTANCELETTER
CONSUMERHANDBOOK
SEVERITYPROFILE(ifindicated)
CURRENT ISP/ IEP/ITP/
InterimDay Hab. Serviceplan
(after5 days ifindicated)
SOCIALHISTORY
MEDICALHISTORY
PHYSIANSAUTHORIZATION(if
indicated)
PHYSICALFORM
ASA HEALTH FORM
COPYOFMEDICALINSURANCE CARD
IMMUNIZATION RECORD
ASA’S AUTHORIZATIONFORMS
(MEDIA/EMPLOYMENT RELEASE)
ASA’S AUTHORIZATION FOR
MONEYMANAGEMENT (COMMUNITYFUNDS,BANK ACCOUNT/ CASH CHECKS)
BIRTHCERTIFICATE
PICTUREIDENTIFICATION
COPYOFSOCIALSECURITY
CARD
GUARDAINSHIPDECREE
GUARDIAN/PARENT/PARTICPANT AUTHORIZATION
Website:
HEALTH HISTORY(YES, NO,GIVE DATES IFAPPICABLE)
NAME: DATE:
CURRENT
MEDICATIONS
SIDEEFFECTSTO
MEDICATION
HEART DEFECT/DISEASE:YESNO DIABETES:YES NO
SEIZURES: YESNO
BLEEDING/ CLOTTING DISORDERS:YES NO ALLERGIES (pleasestate:medications,pollen,mold,
etc.)
ASTHMA YES NO
OPERATIONS OR SERIOUSINJURIES
(DATED)
CHRONIC OR RECURRINGILLNESS(Please
state)
ANY RESTRICTEDACTIVITIES:YES NO IFYES, PLEASE STATE:
PHYSICALLYFIT TOWORK:YESNO
OTHER PERTINENTINFORMATION:
HASTHEINDIVIDUALHADALLIMMUNIZATIONS TB(DATE)
INCLUDING
DATE OFLAST PHYSICAL
Doctor
Doctors Address &phonenumberinclude hospital
Height
Weight_
SPECIAL
DIET
NUTRITION(CIRCLE)GOODPOOROBESEUNDERWEIGHT
IFTWOPLEASEGIVE BOTHOFMEDICAL INS./MEDICAID &
#
Insurance Carrier
PLEASE INCLUDE THE FOLLOWING INFORMATION CURRENT PHYSICAL SIDE EFFECTS TO MEDICATION
DENTIST_
DATE OFLAST EXAM
Information,Referral,Education,SupportedEmploymentandRehabilitationServices
ServingCentralandEasternMassachusetts
AUTHORIZATIONS
PARTICIPANT
NAME
1.ThisistoauthorizeASAtoactinsharingtheresponsibilityofthe delegationofsmallamountsofclientfundsforuseinvarious communityexperiencesandactivities.
2.IgiveASApermission,asneeded,to openabankaccountforthe aboveprogramparticipantandtodepositandwithdrawfunds.
3.Igivepermission,asneeded,tocashallpaychecksfortheabove programparticipantandtokeepthosemoniesatASAto beused forcommunityfunds.
4.Iunderstandthatiftheprogramparticipantisplacedina competitiveemploymentjobwhereheorsheispaiddirectlybythe employer,thatIwillparticipatein thepaymentof IRWE (IMPAIRMENTRELATEDWORKEXPENSES),aprogram throughtheSocialSecurityAdministration.
5.Iunderstandthattoensuresafety,iftherearebehavioralissuesthat maycauseself-injury,injurytoothersorpropertydestruction,that restraintandcontainmentmaybeusedorthat911maybecalled.
Signature(Guardian,ifindicated)/Date
Website:
Information,Referral,Education,SupportedEmploymentandRehabilitationServices
ServingCentralandEasternMassachusetts
RELEASEOFMEDIAINFORMATION
I hereby givemy permissionto AutismServices Association, Inc., to releasepersonal informationto themedia including newspapers, TV, radio, etc.
I give consent to the following specific media event(s) with the following restrictions (ifany)
ASA’s FACEBOOK, WEBSITE PAGE AND BROCHURE
I hereby give consent voluntarily, without threatof punishment of prompts ofspecial reward. I havebeengiven theopportunityto fully discuss the releaseofmedia information andto havemy questions answered. I understandthatI may withdrawconsent atany time prior to releasewithout fearof punishment or reprisal.
Signature/ Date
I havefully explainedthe releaseofinformation fromaboveandansweredall questions to the bestofmy ability. Itis my opinionthat consent has beengiven knowingly andfreely.
(Person obtaining consent) Date
Title, AutismServices Association, Inc.
ExpirationDate– (not to bemore thanoneyear)
Website:
Information,Referral,Education,SupportedEmploymentandRehabilitationServices
ServingCentralandEasternMassachusetts
EMERGENCYMEDICAL TREATMENT PERMISSIONFORM
Inthe event ofa medical emergency, I hereby authorizeemergencymedical treatment for: (Name)
Parent/Guardian/Date
DateofBirth:
NameofHealthPlan:_
HealthPlanID#:
Any pertinentmedical
information:
Website:
Information,Referral,Education,SupportedEmploymentandRehabilitationServices
ServingCentralandEasternMassachusetts
RELEASEOFEMPLOYMENT INFORMATION
I hereby givemy permissionto AutismServices Association, Inc. to release pertinent employment information for thesolepurposesofobtaining employment. This materialwill beusedinsearchingfor jobopportunities andwillbegiven only to thosepersons responsible forhiring.I give consent, on the conditionthat thematerialreleased beused only for theabove reasonwith thefollowing restrictions, ifany:
I hereby give consent voluntarily, without threatof punishment orprompts ofspecial reward. I havebeengiven theopportunity to fully discuss the releaseandto havemy questions, ifany, answered. I understandthatI may withdrawconsent atany timepriorto releasewithout fearof punishment or reprisal.
Signature / Date
I havefully explainedthe releaseofinformation formaboveandansweredall questions to the bestofmy ability. Itis my opinionthat consent has beengiven knowingly andfreely.
(person obtaining consent) Date
(Title) AutismServices Association, Inc
ExpirationDate– Not to bemorethanoneyear
47 WalnutStreet, Wellesley Hills, MA 02481
TEL:(781)237-0272Fax:(781)237-5020
E-Mail:
Website:
Information,Referral,Education,SupportedEmploymentandRehabilitationServices
ServingCentralandEasternMassachusetts
AUTHORIZATIONTOATTEND AUTISMSERVICES ASSOCIATON’S DAY HABILITATIONPROGRAM, PARTICIPATEIN THEIR DAY HABILITATION SERVICEPLAN ANDRECEIVEALLIED HEALTHTHERAPY EVALUATIONS.
I approvethat
attend ASA’s DayHabilitation
Program and participate in his/her individual DayHabilitation ServicePlan, including: Self-help, Sensorimotor, Communication, Social,IndependentLiving,Affective andBehavioral Development areas, includingthe allied health evaluations of: physical therapy, occupational therapy, speech therapy,and behavioraltherapy.
Physician’s SignatureDate
47 WalnutStreet, Wellesley Hills, MA 02481
TEL:(781)237-0272Fax:(781)237-5020
E-Mail:
Website:
Information,Referral,Education,SupportedEmploymentandRehabilitationServices
ServingCentralandEasternMassachusetts
To ASA
Date:
I approve thatmy son/daughterattendASA Day HabilitationProgram
Participant:
Participant/Parent/Guardian Signature: