APPLICATION FOR SERVICES - Systems Unlimited, Inc.

APPLICATION FOR SERVICES2533 South Scott Boulevard, Iowa City, Iowa 52240Your (Applicant) Name:Date:Your Current Address:City:State: Zip Code: Phone:How did you hear about Systems Unlimited?Please check service(s) applying for:A. Supported Community Living Services C. RespiteChildren’s servicesAdult servicesDrop-In/Hourly servicesChild # of hours needed per monthAdult # of hours needed per monthChildAdultB. Vocational Services _______ Day Programming ________Birth Date: Sex: Height: Weight:_______Social Security Number: ____________________Primary Disability (Degree and Type):Other Diagnoses:Ambulatory: Yes NoPrimary language and method of communication:County of Financial Responsibility:Funding: ID Waiver: BI Waiver: _____ Habilitation Waiver: ____ Elderly Waiver ____RBSCL/Waiver eligible (children only):______ State Case:______ 100% County Funded______Private Pay:_______ ARO:______Case Manager: Phone #:Address:City:State:Zip:Revised 2/02, 10/09 1

Social Worker: Phone #:Address:State:Reason for referral:Zip:City:Expectations of services:Please explain amount of supervision necessary and why:Are you ever left alone?If yes, how long?Do you take the bus or do activities in the community on your own?Other community agencies involved:Contact Person/Address/PhoneFAMILY INFORMATIONFather’s Name Phone: Home: Work:Address:Mother’s Name Phone: Home: Work:Address:Revised 2/02, 10/09 2

Involved Family Members:Address/Phone:FINANCIAL / LEGAL INFORMATIONDo you receive financial assistance? YesNoIf yes, give type of assistance:Income other than financial assistance (Yearly Amount)Do you have a payee? Yes NoYearly Amount:If yes, who?Savings Account: Yes No Checking Account: Yes NoDo you have Life insurance? YesNoDo you receive Medicaid Insurance? Yes No #:Do you receive Medicare Insurance? Yes No #:Other health insurance? Yes No Company and #:Do you have a funeral trust? Yes ____ No ____ If yes, with whom and amount of trust?_____________________________________________________________________________________Other Assets / Resources:If applicable, who has legal custody or guardianship? Mother Father Both ParentsIf other than parents, please specify: Name:Address:Phone:Date of guardianship:PLEASE ATTACH A COPY OF GUARDIANSHIP PAPERS AND FUNERAL TRUST PAPERSWITH THIS APPLICATION.Do you have a will? Yes No A Trust? Yes NoDo you have a Power of Attorney? Yes No A Burial Plan? Yes NoRevised 2/02, 10/09 3

CURRENT MEDICATIONSName Dose Frequency Reason for medicationMEDICAL INFORMATIONCurrent Doctor:Address:Current Dentist:Address:Date of last exam:Phone:Date of last exam:Phone:Do you have dentures? YesNoOther Specialist:Address:Date of last exam:Phone:Reason:Other Specialist:Address:Date of last exam:Phone:Reason:Other Specialist:Address:Date of last exam:Phone:Reason:Have you been hospitalized in the last 5 years? YesNoIf yes,, please explain:Revised 2/02, 10/09 4

Have you ever received any mental health services? YesNoIf yes, please explain:ALLERGIESAre you allergic to:Medication? Yes No If yes, please explain:Food? Yes No If yes, please explain:Other? Yes No If yes, please explain:DIETAre you on a special diet? Yes No Please explain:SEIZURESDo you have seizures? YesNoAge of onset:Date of last seizure:Frequency of seizures:Describe a typical seizure:ACTIVITYList activities / organizations you are involved in:List all activities or limitations you are restricted from as ordered by a medical doctor:Revised 2/02, 10/09 5

Do you have any physical disabilities that require the use of special devices? (Wheelchair, braces,walker, orthopedic shoes, splints, canes, etc.) Please explain:MEDICAL HISTORYAre you able to communicate medical needs/concerns? Please explain:Illnesses Experienced:Chicken Pox German Measles PneumoniaMeasles Polio CroupMumps Whooping Cough TuberculosisScarlet Fever Rheumatic Fever HepatitisOther:FEARSDo you have any fears that would be important for us to know? (heights, dogs, enclosed spaces, etc.)EDUCATIONAL HISTORYSchool Name Address City State Zip Dates AttendedSchool Name Address City State Zip Dates AttendedSchool Name Address City State Zip Dates AttendedRevised 2/02, 10/09 6

VOCATIONAL / EMPLOYMENT HISTORYEmployer / Agency: From: To:AddressStateZipCityJob Responsibilities:Reason for Leaving:Employer / Agency: From: To:AddressStateZipCityJob Responsibilities:Reason for Leaving:Employer / Agency: From: To:AddressStateZipCityJob Responsibilities:Reason for Leaving:*** If a vocation referral is being made please supply needed information to complete the I-9 form toreferral contact.**** (See page 11 of this application for more information)Revised 2/02, 10/09 7

Please check the items which best describe your abilities.SKILLS CHECKLISTEATING / DRINKINGNeeds assistance with eating / drinkingAble to eat independentlyUses adaptive aids/devicesYES NOComments: Types of prompts/instructionsneededDRESSINGNeeds assistance with dressingAble to dress independentlyPERSONAL HYGIENENeeds assistance with hygieneConducts hygiene independentlyUses adaptive aids/devicesTOILETINGUses incontinent aidsScheduled toiletingCan indicate needAssistance transferring on/off the toiletCompletely independent in toiletingCares for self during menstrual cycleMEDICATIONSNeeds assistance when taking medicationsTakes medications independentlyCooperates with taking medications8Revised 2/02, 10/09 8

YESNO COMMENTSCHORES AND ACTIVITIESDoes household tasks with assistanceDoes household tasks independentlyDoes laundry with assistanceDoes laundry independentlyCooks meals with assistanceCooks meals independentlyRequires supervision in publicMakes purchases with assistanceMakes purchases independentlyUses public transportation (bus, taxi) with assistanceUses public transportation independentlyPursues leisure interests independentlySLEEPING HABITSSleeps through the nightHas a routine for sleepSleep walksExperiences sleep disordersWakes up with alarm clockHUMAN SEXUALITYUnderstands the difference between males and femalesDisplays sexually appropriate behaviorSexually active9Revised 2/02, 10/09 9

COMMUNICATIONYES NO COMMENTSRelates experiencesUnderstands speechCommunicates by signingCommunicates with augmentative devicesSpeaks single words/phrases/sentencesSpeech easily understoodFollows simple directionsTalks on telephoneKnows how to dial a phonePrints/writesAsks for helpSOCIAL RELATIONSInteracts with peersInteracts with members of the opposite sexInvolves self near, but not with othersParticipates in group activitiesMaintains friendshipsEngages in datingHas a significant otherPrefers to be alone at timesSAFETY ISSUESResponds to a smoke alarmKnows how to use Basic First Aid10Revised 2/02, 10/09 10

The Following Must Be Attached with the Application to be Considered for Program If seeking vocational opportunities: A Copy of Birth Certificate, Social Security Card,and State Issued Photo ID (For tax forms) Initial SUI referral Most Current ISP/Behavior Plan (if applicable) County Plan Attach a Copy of the Applicants Safety Plan Psychological Evaluation with Diagnosis. OTHER Specified Upon RequestIf you need help obtaining any of these items or have any questions, please call 338-9212 ext.880.Revised 2/02, 10/09 11

YES NO COMMENTSBEHAVIOR INFORMATIONHyperactiveWithdrawnMakes disruptive noisesDisplays self-stimulating behaviorsDisplays harmful/self injurious behaviorsMistreatment of propertyAggressive/abusive to othersLeaves home/work without supervisionHistory of substance abuseHas been arrestedPLEASE PROVIDE THE FOLLOWING WITH YOUR APPLICATION: If seeking vocational opportunities: A Copy of Birth Certificate, Social SecurityCard, and State Issued Photo ID (For I-9 and applicable tax forms) Most Current Residential ISP/Behavior Plan (if applicable) Case Management Plan Attach a Copy of the Applicants Safety Plan Psychological Evaluation with Diagnosis. Social History/Summary Vocational/Educational Plans from previous placement (if applicable) Other specified documents upon requestThis application was completed by:Name:__________________________________________Phone Number: ____________________________________Relationship to applicant: _________________________________1 1Revised 2/02, 10/09 12