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Provider_Application_for_Transitioning_Youth

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Service applying for:
- Supported Employment
- Day Habilitation
- Community Learning Services
- Other
Other:
Applicant's Information
Name:
First Last
Date of Birth:
MM slash DD slash YYYY
Medicaid/Medical Assistance
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone:
Social Security Number:
Email:
Ethnic Identification (completion is not required):
- African
- Caucasian
- Hispanic
- Naive American
- Asian
- Other
Other
Emergency Contact(s)
Name Relationship to Applicant Address Best way to contact? Home Phone Cell Phone Email
Guardian/Caregiver Name:
First Last
Relationship to Applicant:
Guardian/Caregiver Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Guardian/Caregiver Home Phone:
Guardian/Caregiver Cell Phone
What is the best way and time to reach your Guardian/Caregiver?:
Living Situation:
- Parents
- Relaties
- Guardian
- Other
Other (Please include name)
Parent/Relative/Guardian Name:
First Last
Family Information
Father's Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Work Phone
Date of Birth
MM slash DD slash YYYY
Deceased
- Yes
- No
Date of Death
MM slash DD slash YYYY
Mother's Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Work Phone
Date of Birth
MM slash DD slash YYYY
Deceased
- Yes
- No
Date of Death
MM slash DD slash YYYY
Sibling(s)/Other Family Members living in the household
Name Address Phone Relationship to Applicant Date of Birth
Financial Information
SSI Claim #:
SSI Amount:
SSA Claim #:
SSA Amount:
Name of representative payee/relationship to applicant:
Other sources of Applicants Income:
Account Types:
- Checking
- Savings
Bank Name:
Property in applicant’s name (list location and value):
Trust Fund:
- Yes
- No
Type:
If yes, give name and address of trustee:
Medical Information
Diagnoses (Primary, Additional, etc.):
Medications:
Medication Dosis Frequency Reason
Applicants Medicaid/Medical Assistance #:
Dates Covered under Medicaid/Medical Assistance:
Applicants Medicare #:
Type:
Other Medical Insurance (list company name and policy #):
Applicant’s Primary Physician:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Hospital familiar with Applicant:
Applicant’s Dentist:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Does the applicant wear dentures?
- Yes
- No
Briefly list any dental problem(s):
Does the applicant have a vision impairment?
- Yes
- No
Is the applicant legally blind?
- Yes
- No
Does the applicant wear:
- Glasses
- Reading Glasses
- Contact Lenses
Does the applicant have a hearing impairment?
- Yes
- No
Does the applicant wear a hearing aid?
- Yes
- No
Is the applicant deaf?
- Yes
- No
Does the applicant have seizures?
- Yes
- No
Frequency:
Type:
Are seizures controlled by medication?
- Yes
- No
Does the applicant have a speech or language impairment?
- Yes
- No
Is the applicant verbal?
- Yes
- No
Has the applicant had a speech/language assessment?
- Yes
- No
Assessment completed by:
Date of Assessment:
MM slash DD slash YYYY
Applicant means of communication:
- Speech
- Sign Language
- Gestures
- Communication Board
Mobility:
- Walks Independently
- Uses Cane
- Uses Crutched
- Uses Walker
- Uses Wheelchair
Type of Wheelchair:
Can the wheelchair user:
- Transfer Independently
- Needs Assistance
Can the applicant cross streets?
- Independently
- With Assistance
- No
Can the applicant use mass transit?
- Independently
- With Assistance
- No
Is the applicant certified to use Paratransit/MTA Mobility?:
- Yes
- No
Does the applicant have any other medical conditions not listed above?
Has the applicant had any significant surgeries or hospitalizations?
Does the applicant have a special diet, use adaptive dishes/utensils, or need feeding assistance?
Does the applicant have any allergies (environmental, medication, foods, etc.)?
Does the applicant:
- Use the bathroom independently
- Wear diapers
- Need transfer assistance to the toilet
Applicant’s Current Psychiatrist:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Applicant’s Current Psychologist:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Applicant’s Current Therapist:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Does the applicant have a history of behavioral problems?
- Yes
- No
Does the applicant have a current behavior plan in school?
- Yes
- No
If yes, please briefly explain below (use additional paper if necessary):
Education
Schools or Adult Programs Attended :
Program Address Dates Attended
Vocational Programs or Trainings Attended:
Program Address Dates Attended
Is the applicant independent in personal self-care skills? (e.g. bathing, dressing, feeding, toileting)
- Yes
- No
Can the applicant self-medicate?
- Yes
- No
Is the applicant capable of remaining home unsupervised?
- Yes
- No
If yes, for how long:
Can the applicant read?
- Yes
- No
If yes, what level:
Can the applicant write?
- Yes
- No
If yes, what level:
Does the applicant sleep through the night?
- Yes
- No
What time does the applicant usually go to bed?
Get up in the morning?
What does the applicant like to do with their free time?
Please provide a brief description of the applicant's daily routine:
Has the applicant received or is the applicant currently receiving any types of services or financial assistance (i.e. Rolling Access funds, respite Services, In-Home Support Services, Foster Care, etc.)? If yes, please list below:
Employment
Is the applicant currently employed?
- Yes
- No
If yes, what is the employment address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Supervisor's Name:
Job Title:
Start Date:
MM slash DD slash YYYY
Wage:
Previous Employment:
Company Name Company Phone # Job Title Supervisor’s Name Dates Employed
If the applicant is not currently employed, what are their job interests?
Does the applicant have a Service Coordinator?
- Yes
- No
If yes please state name and phone number:
Does the applicant have a current DORS Counselor?
- Yes
- No
If yes please state name and phone number:
Does the applicant have a current Social Worker?
- Yes
- No
If yes please state name and phone number:
Signature of Applicant (if over 18 year old)
Date
MM slash DD slash YYYY
Signature of parent/guardian (if applicable)
Date
MM slash DD slash YYYY
Signature of Person Completing the Form
Date
MM slash DD slash YYYY

Name	Relationship to Applicant	Address	Best way to contact?	Home Phone	Cell Phone	Email

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

Medication	Dosis	Frequency	Reason

Program	Address	Dates Attended

Program	Address	Dates Attended

Upload Your Application

Applicant's Information

Family Information

Financial Information

Medical Information

Education

Employment

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