new enrollment packet - magnoliaspecializedservices.com enrollment pack… · web viewlist any...

New Enrollment Packet

Magnolia Specialized Services, Inc. (870)-234-6118 or (870)-234-4118

_____Physical Examination

_____Prescription for Services

_____Psychological

_____Emergency Medical and Field Trip Release

_____Face Sheet

_____Social History

_____Diploma

_____Application for Services

_____Copy of Medicaid Card

_____Legal Guardianship


Medical Necessity Statement

Due to this person’s medical necessity, I hereby prescribe the following service/services for_________________________ (Individual’s Name)

Day Habilitation – DDTCS

Evaluation

Transportation

____________________________ ____________ Physician’s Signature Date

____________________________ _____________ Physician’s Name Provider Number


Physical Examination

Name: _______________________ Date: _____________General Appearance: _________________________________________Height_____ Weight_____ Pulse_____ Resp_____ B/P_____ Temp______Check “normal” findings with “O”. Check “abnormal” findings with “X”.Describe the abnormal findings in the space at the right.

1. ____Head2. ____Eyes (including vision as best can be determined)3. ____Ears (whisper voice 10 feet)4. ____Nose 5. ____Throat6. ____Teeth7. ____Mouth8. ____Neck9. ____Chest and Lungs10.____Breasts11.____Heart12.____Abdomen 13.____Genitalia and Rectum14.____Pap Smear15.____Back, Bones, Joints, and Extremities 16.____Skin, Lymphatic, Hair17.____Muscular18.____Nutrition

Neurological

19.____Cranial20.____Cerebellum21.____Sensory22.____Motor23.____Operations24.____Other Findings25.____Person’s health and medical condition explained to person

Diagnosis________________________________________________________Medications_______________________________________________________Recommendations___________________________________________________Physician’s Signature______________________________________

Emergency Medical and Field Trip Release


I give my permission to go on field trips planned by the Verbie Graney CARC Center as part of the regular curriculum (Pizza Inn, Bowling, Library, etc.).

Signature of Individual: ___________________

Parent of Guardian: ______________________(If applicable)

In case of medical emergency requiring more attention than normal first aid, please take me _________________________ to Doctor ____________________________. If this doctor is not available, use Doctor ___________________________.

Signature of Individual: __________________________.

Parent of Guardian: _____________________________.(If applicable)

Date: ____________Witnessed by: _____________________


Individual Face SheetName: ____________________________ Social Security #: _______________Address: ____________________________ Telephone #: __________________ Cell Phone #: __________________ Date of Birth: __________________Sex: __________ Race: ____________ Legal Status: ___________________Marital Status: _______________ Parent Guardian Name: _____________________Address: _______________________________________ Telephone #: __________________

Emergency Contact Name: _______________________________(Other than listed above)Relationship: _______________________________Address: _______________________________ Telephone #: __________________

Health Insurance & Number: ___________________________________________Admission Date: _____________ Primary Language: ____________Primary Handicapping Condition: ___________________________________Secondary Handicapping Condition: __________________________________Physician’s Name: ___________________________Address: ____________________________________ Telephone #:_________________Current Medications & Dosage: ____________________________________________________________________________________________________________________________________________________________Allergies/Dietary Restrictions: ___________________________________________________


Case Manager: _________________________________ Date: ____________



Social History

Applicant: _____________________ Date: __________Address: _______________________ _______________________________Phone #: _______________________DDS SC: _______________________

I. Physical Description (General Description)

Marital Status: ________________________ Hair Color: ____________Height: ______________________ Eye Color: _____________Weight: _____________________ Race: ________________

II. Diagnosis (Check and complete appropriate blanks)

_____ Developmental Delayed_____ At risk for delay due to medical condition (identify condition) _________________________________________________________ Mental Retardation (Level if known) __________________________________ Epilepsy _____________________________________________ Seizures (type/frequency) _______________________________________


_____ Cerebral Palsy (functioning level if known) ______________________________ Autism (functioning level if known) ____________________________________ Adaptively eligible ___________________________________________________ Other, Please explain ____________________________________________

III. Services Requested and Current Situation

a. What assistance is needed and why? ____________________________________________________________________________________________________________________________________

b. Does individual presently reside with family? (If no, please explain.)____________________________________________________________________________________________________________________________

(III. Continued)c. Is present living situation satisfactory? (if not, please specify)

____________________________________________________________________________________________________________________________________

d. List agencies, schools, programs, etc., presently assisting applicant and services provided: ______________________________________________________________________________________________________________________________________________________________________________________________________

IV. Give the names, addresses, and phone numbers for the following:

Pediatrician __________________________________________________________Family Doctor ________________________________________________________Dentist ______________________________________________________________


Nurse _______________________________________________________________Orthopedist__________________________________________________________Ear, nose, and throat specialist _________________________________________Ophthalmologist _____________________________________________________Psychiatrist/Psychologist ______________________________________________Audiologist __________________________________________________________Speech Therapist _____________________________________________________Occupational Therapist ________________________________________________Physical Therapist ____________________________________________________Social Worker ________________________________________________________Dietician ____________________________________________________________Others (please specify) ________________________________________________

List any other agencies, programs, services considered, but not used, and reasons not used. __________________________________________________________________________________________________________________________________________List other agencies, schools, training facilities, and programs that have assisted applicant in the past, and services they provided. __________________________________________________________________________________________________________________________________________

(IV. Continued)Any past services requested from DDS or other agencies, and whether or not services were received, if not, why? __________________________________________________________________________________________________________________________________________


V. Family InformationFather

Name: ______________________ SSS: ______________________ DOB: ________Address: _________________________________________ Phone: ____________Deceased ______ Retired _______ Disabled _______Military: Active _______ Retired_______ Branch________Employer: ______________________________________ Phone: ______________Salary Estimate: _______________________________________

MotherName: ______________________ SSS: ______________________ DOB: ________Address: _________________________________________ Phone: ____________Deceased ______ Retired _______ Disabled _______Military: Active _______ Retired_______ Branch________Employer: ______________________________________ Phone: ______________Salary Estimate: _______________________________________

Does applicant have any income? (If yes, how much and what type?)__________________________________________________________________________________________________________________________________________

List Children Age Child Income Source Payee_______________ ______ ____________ __________ ___________________________ ______ ____________ __________ ___________________________ ______ ____________ __________ ____________

Please list AFDC, VA, SSI, SSA, Child Support, Trust, and PayeeType Amount Individual Payee________________ _________ _____________ _____________


________________ _________ _____________ _____________________________ _________ _____________ _____________

(V. Continued)List any other close family members: _______________________________________________________________________________________________________________________________________________________________________________________________________________

VI. Developmental/Behavioral Profile

Answer appropriately (yes or no and list age)

Yes No Age Yes No AgeSat Alone ____ ____ ____ Toilet Trained ____ ____ ____Crawled ____ ____ ____ Bowel ____ ____ ____Walked Alone ____ ____ ____ Bladder ____ ____ ____Made sound/ babble

____ ____ ____ Dry at Night ____ ____ ____

Single word ____ ____ ____ Pronounced Clear ____ ____ ____Phrases/Sent. ____ ____ ____ Understood by mom ____ ____ ____Says Words Correct ____ ____ ____ Understood by others ____ ____ ____

Areas of Concern

____ Walk ____ Dress Self ____ Prepare Own Needs____ Talk ____ Write/Print ____ Bathe/Groom Self____ See ____ Tell Time ____ Travel Alone____ Hear ____ Use Toilet ____ Work Independently____ Read ____ Feed Self ____ Wash Clothes____ Recognize Money ____ Self-medicate____ Communicate ____ Use Telephone

Behavioral Profile

Does Applicant have challenging behavior/temper tantrums? (Explain)____________________________________________________________________________________________________________________________________________________________


Behavioral Profile (cont.)

Describe applicant’s typical behavior with regard to:Activity Level

___________________________________________________________Aggressive or

Passive_____________________________________________________Reactions to

others_______________________________________________________

Describe any unusual/extreme behavior of applicant (and frequency) with regard to:

Reaction to authority ____________________________________________________________________________________________________________________________________________________________Non-compliant/oppositional behaviors (if yes, explain/describe) ____________________________________________________________________________________________________________________________________________________________Possible injurious episodes (if yes, explain/describe) ____________________________________________________________________________________________________________________________________________________________Any self-stimulatory behaviors (describe) ____________________________________________________________________________________________________________________________________________________________

VII. Medical History

A. Birth Information

Problems during pregnancy (explain) _______________________________________Length of pregnancy _______________ Labor induced/delayed _________________Medications taken during pregnancy _______________________________________Did mother smoke ___________ Drink _______________ Drugs ______________Did father smoke ____________ Drink _______________ Drugs _______________


List infections: Mother ___________________________________________________ Father____________________________________________________Birth Weight ________________ APGAR ____________________________________Complications __________________________________________________________Hospital _________________________________ Length of Stay _________________

B. Individual’s Information

Has the applicant been tested for hearing? __________________________________If yes, when? _________________________ Where? ___________________________What were you told? _____________________________________________________Medical History (cont.)

Current Medications (type & dosage) ________________________________________________________________________________________________________________________________________________

Check all that apply:_____ Asthma/respiratory problems_____ Allergies_____ Infections_____ High Fever (104+), duration_____ Operations (including tubes in ears)_____ Special diet needs (if any)_____ Other health concerns or needs/childhood diseases (specify) ________________________________________________________________________________________________________________________________________________

Medical Procedure Needs (list any special requirements on the right)

_____ Catherization Provider _____________________________________________________________________________________________________________________________________________________ Hyper alimentation Provider ________________________________________________________________________________________________________________________________________________


_____ Injections Provider _____________________________________________________________________________________________________________________________________________________ Intervenous Provider_____________________________________________________________________________________________________________________________________________________ Respiratory Care _____________________________________________________________________________________________________________________________________________________ Suctioning Provider _____________________________________________________________________________________________________________________________________________________ Tracheotomy Care _____________________________________________________________________________________________________________________________________________________ Tube Feeding Provider ________________________________________________________________________________________________________________________________________________

VIII. Person- Centered Planning Information

Preferred activities (games, toys, etc.) ______________________________________________________________________________________________________________________________________________________

How does the applicant get along with other people? ____________________________Children? __________________________ Adults? ________________________________

How does the applicant usually react to separation from parent or caregiver, or familiar surroundings? ______________________________________________________________________________________________________________________________________________________

What goals would you like to see the applicant achieve? ______________________________________________________________________________________________________________________________________________________

How can the family/friends/others help? ______________________________________________________________________________________________________________________________________________________


How do you feel the agency can help? ______________________________________________________________________________________________________________________________________________________

_____________________________ _________________ Informants Signature Date

_____________________________ Relationship to Applicant

Services Needed/Recommended:

A brief statement of the service coordinator/program staff’s assessment of the individual, family’s needs. Include options discussed with individual, family, or concerned party.

Recommendations of service(s) needed to assist the individual and who might provide the services, with time frames, if appropriate.

Comments: (attach other pages if necessary)______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_________________________________________ ________________ DDS Service Coordinator/Program Staff Date

Department of Human ServicesDivision of Developmental Disabilities Services

Application for Services

Date of Application _______________Applicant’s Name ______________________________________________Applicant’s Address ____________________________________________________________________________________________________________________________________________________________County __________________Telephone # ___________________________________Legal Status ___________________________________Applicant’s Social Security # __________________________________Applicants Medicaid # _______________________________________Applicants Medicare # _______________________________________Insurance Company Name and # ____________________________________________________________________________________________________________________________________________________________

S.S.I. Recipient


Yes No

Social Security Disability

Yes No

Name of Parent/Guardian _______________________________________________________

Address ____________________________________________________________________________________________________________________________________________________________

County ________________ Telephone ____________________________________________

Application for Services (cont.)

Relationship __________________________________________________________________Work Address _________________________________________________________________Work Telephone # _____________________________________________________________Directions ____________________________________________________________________________________________________________________________________________________________

Primary Disability _____________________________________________________________Secondary Disability ___________________________________________________________

Applicant’s Physician ___________________________________________________________


Physicians Address ____________________________________________________________________________________________________________________________________________________________Telephone # __________________________________________________________________Services Requested ____________________________________________________________________________________________________________________________________________________________

Emergency ContactName___________________________________________________________Address ____________________________________________________________________________________________________________________________________________________________Telephone # __________________________________________________________________

Referred by: ____________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________ Signature of parent or guardian

________________________________________________ _________________ Relationship Date


________________________________________________ _________________ Witness Date(If person is not incapacitated but unable to sign due to physical disability)

Unless the person is legally incapacitated, he/she must sign this form. If he/she is legally incapacitated, it must be signed by the personal guardian (accompanied by proof of guardianship). If person is not incapacitated but unable to sign because of physical disability, his/her mark or consent must be witnessed.

new enrollment packet - magnoliaspecializedservices.com enrollment pack… · web viewlist any...

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