Rem Iowa Service Application Form – Fill Out and Use This PDF

The REM Iowa Service Application Form serves as a comprehensive document designed for individuals seeking ID/DD/MH services within Iowa. It gathers detailed information about the applicant, including personal, financial, medical, and service history, to facilitate a tailored approach to their care and support needs. Those interested in applying for services can ensure a smoother process by completing this form with the necessary details.

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Rem Iowa Service Application Form PDF Details

The REM Iowa Service Application form is a comprehensive document designed to collect essential information from individuals seeking ID/DD/MH services within Iowa. This form encompasses various sections, including applicant information, legal guardianship status, financial responsibility, desired services, history of services, referral history, family information, the applicant's financial and health/medical information, as well as behavior and leisure activities. Applicants or their guardians are required to provide detailed answers about the applicant's personal and medical history, current living situation, and the specific types of services they are seeking, such as 24-hour waiver, habilitation, or host home services. The form also inquires about any legal issues, family details, financial status including insurance and benefits, and health-related information, which includes medication, physical disabilities, and behavioral tendencies. The closing section emphasizes the confidentiality and intended use of the provided information, promising that it will be used solely for facilitating the application process unless otherwise authorized by law. This ensures applicants of the privacy and security of their personal data. Additional documentation to support the application—like psychological evaluations or medical reports—is also encouraged to be attached for a more comprehensive review. Designed to streamline the application process for both applicants and administrators, this form plays a crucial role in connecting individuals with the appropriate services and support within the REM Iowa network.

Question	Answer
Form Name	Rem Iowa Service Application Form
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	rem application, Adel, rem iowa employee portal, amazon

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REM IOWA COMMUNITY SERVICES & REM IOWA DEVELOPMENTAL SERVICES

SERVICE APPLICATION FORM FOR ID/DD/MH SERVICES

Date of Application:

REFERRAL TO REM IOWA

How did you become aware of REM Iowa services?

Family | Friend

REM Iowa website

The MENTOR Network website

Hospital

REM Employee

Other Provider

Case Manager | Care Coordinator

Other

If other, please document from whom/where:

APPLICANT INFORMATION

Applicant’s Full Name:

When Desired:

Placement in Jeopardy

Next Available

Within six months

Within one year

If placement in jeopardy, indicate the date of discharge:

Current Address:

Telephone Number:

Birth Date:

Gender:

Male

Female

Height:

Weight:

lbs.

Primary Diagnosis:

Intellectual Disability

Mental Health/Illness

Autism Spectrum:

Yes

Personality Disorder:

Yes

Schizophrenia or Schizoaffective Disorder:

Yes

Other Diagnosis:

LEGAL GUARDIANSHIP STATUS

Does this applicant have a guardian?

Yes

Name of Guardian:

Relationship:

FINANCIAL RESPONSIBILITY

Case Manager | Care Coordinator Name:

Telephone Number:

Email:

IME Determination Date:

Level of

Care:

SERVICE(S) DESIRED

Type of Services Desired:

ICF/ID

24-hour Waiver (Adult)

24-hour Habilitation

Host Home**

Communities desired:

Day Habilitation (*indicates available communities below)

Unknown

1. Children ICF/DD (ID must be primary diagnosis):

Council Bluffs Only

Adult ICF/DD (ID must be primary diagnosis):

1st Opening

Shelby

Washington

Coralville

Cedar Rapids | Marion | Hiawatha

No preference

Waiver Services:

1st Opening

Des Moines Area*

Mt. Pleasant

Atlantic

Ft. Madison

Mt. Vernon

Avoca

Harlan

Shelby

Cedar Rapids |Marion| Hiawatha*

Iowa City|Coralville*

Tipton

Clinton

Keokuk

Vinton*

Council Bluffs

Marshalltown*

Waterloo | Cedar Falls |Waverly

Davenport | Bettendorf

Mason City

No Preference

Other community (s):

**Host Home is a service where individuals live in private family homes and receive specialized assistance from a dedicated caregiver we call a Mentor.

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Revised 03.17

HISTORY OF SERVICES

Residential/ in-home services (e.g. hourly services, 24-hour waiver, ICF/ID, nursing home, etc.)

Has the applicant always lived at home?	Yes	No

Service	Provider

Dates

Day/Vocational Services
Has the applicant ever been employed:	Yes	No	At a day program?	Yes	No

Service

Provider

Dates

REFERRAL HISTORY

Has the applicant ever been arrested?

Yes

If yes, provide: Date(s):

Reason(s):

Outcomes:

Does the applicant have a current court committal?	Yes	No
Has the applicant been accused/convicted of sexual abuse?			Yes	No
If yes, provide: Date(s):
Outcomes:
Has the applicant had any history of cruelty to animals?			Yes	No
If yes, provide: Date(s):
Outcomes:
Has the applicant attempted suicide or had suicidal ideations?			Yes	No
If yes, provide: Date(s):
Outcomes:
Has the applicant had any history of fire setting?			Yes	No
If yes, provide: Date(s):
Outcomes:
Has the applicant had any history of cutting self, swallowing or insertion of foreign objects or			Yes	No
strangulation?
If yes, provide: Date(s):
Outcomes:
Has the applicant had physical aggression that required physical, mechanical or chemical restraint
via injection over the past 12 months?			Yes	No

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Revised 03.17

FAMILY INFORMATION

Mother’s Name (first & last):

Address:

Home Telephone #:

Work Telephone #:

Email Address:

Father’s Name (first & last):

Address:

Home Telephone #:

Work Telephone #:

Email Address:

Sibling’s Full Name(s) (first & last):

Significant Other Name (first & last):

Address:

Home Telephone #:

Work Telephone #:

Email Address:

APPLICANT’S FINANCIAL INFORMATION

Receive Financial Assistance:

Yes

If yes, type:

SS (Social Security)

SSI (Supplemental Social Insurance)

If other, document type:

VA (Veteran’s Benefits)

Child Support

Adoption Subsidy

Other

Does applicant have Title 19?

Yes

Managed Care Organization (MCO)?

Amerihealth Caritas

Amerigroup

United Health

Optum N/A

Does applicant have Waiver funding?

Yes

Does applicant have Habilitation funding?

Yes

Does applicant have private insurance?

Yes

Does applicant have other income (trust fund, etc.)?

Yes

APPLICANT’S HEALTH/MEDICAL INFORMATION

Current Medication(s) or can attach current medication orders or record:

Name	Dose	Frequency	Reason for Taking

Prescribed By

Page|3 of 5

Revised 03.17

Physical disabilities that require the use of adaptations (e.g. AFOs {braces}, orthopedic shoes, cane, walker, wheelchair,

etc.)	Yes	No
If yes, list adaptive equipment:
Seizures:	Yes	No	History of
If yes or history of, describe type and frequency:
Vision Problems:		No	Yes – correctable with glasses		Yes – but chooses not to wear glasses
		Yes - uncorrected		Blind Comments:
Hearing Problems:		No	Yes – correctable with hearing aides		Yes – but chooses not to wear hearing aides
		Adapt by others speaking louder			Deaf

Comments:

Skill Checklist: (please check items which best describe applicant)

BEHAVIOR	Consistently Sometimes Never Comments
Becomes upset when
redirected/corrected
Demands excessive
attention from others
Complains of being
persecuted
Pretends to be ill
Changes mood without reason
Bosses or manipulates others
Hyperactive
Hoards things
PICA (eats inedible objects) (if
displays, list items in
comments)
Self stimulation
Self injurious behavior
Verbally aggressive
Physically aggressive toward
others
Physcially aggressive toward
objects
Displays sexually inapprorpriate
behavior
Removes clothing in public
Tears clothing
Steals other's belongings
Elopes / runs away from home
Uses tobacco
Uses alcohol
Uses other drugs

Page|4 of 5

Revised 03.17

LEISURE ACTIVITIES

Interests:

Hobbies:

Dislikes:

CLOSING

The information we have asked you to provide is necessary for the effective administration of the services for which you are applying. The information collected will only be used by authorized agency personnel. Use of this information for purposes other than expressed herein will not occur without your prior written approval, unless such other use is specifically authorized by law.

Attach any of the following materials that may be helpful in determining eligibility for service:

Most recent psychological evaluation

Most recent education and/or vocational report

Most recent progress reports or plan of care

Physical and/or specialty medical examinations

Other Documentation that you feel would be helpful


Completed by:
Applicant Name:					Date:
Case Manager Name:					Date:
Parent/Guardian Name:					Date:
Name/Title:					Date:

Please return form to: REM Iowa (please check website for current contact information @ www.remiowa.com)

or send to REMIowaReferral@thementornetwork.com

Page|5 of 5

Revised 03.17

How to Edit Rem Iowa Service Application Form Online for Free

Our PDF editor makes it easy to complete documents. You won't have to do much to change rem iowa employee portal files. Simply keep to the next actions.

Step 1: Click the button "Get Form Here".

Step 2: Now you are on the file editing page. You may edit, add information, highlight specific words or phrases, insert crosses or checks, and add images.

Feel free to enter the next details to prepare the 1st PDF:

Enter the requested details in the space LEGAL GUARDIANSHIP STATUS Does, FINANCIAL RESPONSIBILITY Case, Yes, No Relationship, Email Level of Care, SERVICES DESIRED Type of Services, Communities desired Children, ICFID, hour Waiver Adult Day Habilitation, hour Habilitation, Unknown, Host Home, Council Bluffs Only Shelby, st Opening Cedar Rapids Marion, and Washington.

Adel LEGAL GUARDIANSHIP STATUS Does, FINANCIAL RESPONSIBILITY Case, Yes, No Relationship, Email Level of Care, SERVICES DESIRED Type of Services, Communities desired Children, ICFID, hour Waiver Adult Day Habilitation, hour Habilitation, Unknown, Host Home, Council Bluffs Only Shelby, st Opening Cedar Rapids Marion, and Washington blanks to complete

Write the valuable particulars once you are on the st Opening Atlantic Avoca Cedar, Des Moines Area Ft Madison Harlan, Mt Pleasant Mt Vernon Shelby, Other community s, Host Home is a service where, Page of, and Revised box.

The field HISTORY OF SERVICES Residential, Has the applicant always lived at, Yes, Service, Provider, Dates, DayVocational Services, Has the applicant ever been, Yes, At a day program, Yes, Service, Provider, Dates, and REFERRAL HISTORY will be where you insert both parties' rights and responsibilities.

Adel HISTORY OF SERVICES Residential, Has the applicant always lived at, Yes, Service, Provider, Dates, DayVocational Services, Has the applicant ever been, Yes, At a day program, Yes, Service, Provider, Dates, and REFERRAL HISTORY blanks to insert

Check the fields If yes provide Dates Outcomes, Has the applicant had any history, Yes, If yes provide Dates Outcomes, Has the applicant attempted, Yes, If yes provide Dates Outcomes, Has the applicant had any history, Yes, If yes provide Dates Outcomes, Has the applicant had any history, Yes, If yes provide Dates Outcomes, Has the applicant had physical, and Yes and then fill them in.

Step 3: Choose the "Done" button. Now it's easy to transfer the PDF document to your electronic device. As well as that, it is possible to forward it via electronic mail.

Step 4: Produce as much as a few copies of the file to remain away from all of the forthcoming concerns.

Rem Iowa Service Application Form – Fill Out and Use This PDF

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