If you are a currently registered Iowa voter and would like to serve as an election judge for the statewide general election on November 3, 2015, the Rem Iowa Service Application Form is now available. You can submit your application online or by mail. Deadline to apply is September 4, 2015. For more information on becoming an election judge, please visit the Secretary of State's website.
You may find information regarding the type of form you wish to complete in the table. It will show you how long it should take to fill out rem iowa service application form, what parts you will need to fill in, and so forth.
Question | Answer |
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Form Name | Rem Iowa Service Application Form |
Form Length | 7 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 1 min 45 sec |
Other names | rem iowa application, Marion, rem iowa jobs, ICF |
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 |
Advertisement |
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REM Iowa website |
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The MENTOR Network website |
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Hospital |
REM Employee |
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Other Provider |
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County Case Manager |
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Other |
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If other, please document from whom/where: |
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APPLICANT INFORMATION |
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Applicant’s Full Name: |
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When Desired: |
Next Available |
Placement in Jeopardy |
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Within six months |
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Within one year |
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If placement in jeopardy, indicate the date of discharge: |
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Current Address: |
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Telephone Number: |
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Birth Date: |
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Gender: |
Male |
Female Height: |
Weight: |
lbs. |
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Primary Diagnosis: |
Intellectual Disability |
Mental Health/Illness |
Intellectual Disability/ID: |
Yes |
No |
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Other Diagnosis: |
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LEGAL GUARDIANSHIP STATUS |
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Does this applicant have a guardian? |
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Yes |
No |
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Name of Guardian: |
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Relationship: |
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COUNTY OF LEGAL SETTLEMENT/ FINANCIAL RESPONSIBILITY |
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County of Financial Responsibility: |
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Case Manager Name: |
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Telephone Number: |
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Email: |
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IME Determination Date: |
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Level of Care: |
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SERVICE(S) DESIRED
Type of Services Desired: |
ICF/ID |
Host Home |
RBSCL |
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Vocational |
Unknown |
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Communities desired: |
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1. |
Children ICF/ID (ID must be primary diagnosis): |
Council Bluffs Only |
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2. |
Adult ICF/ID (ID must be primary diagnosis): |
1st opening |
Kalona |
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Shelby |
Washington |
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Coralville |
Cedar Rapids | Marion | Hiawatha |
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No preference |
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3. |
Waiver Services: |
1st Opening |
Adel |
Avoca |
Atlantic |
Davenport |
Keokuk |
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Cedar Rapids | Marion | Hiawatha |
Harlan |
Des Moines area |
Ft. Madison |
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Iowa City|Coralville |
Shelby |
Tipton |
Mt. Pleasant |
Mt. Vernon |
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North Liberty |
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Council Bluffs |
No preference |
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4. |
Host Home |
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5. |
Vocational: |
Adel |
Avoca |
Hiawatha |
Mt. Vernon |
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6. |
Other community(s): |
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Page 1 of 8
HISTORY OF SERVICES
Residential/
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
Has the applicant ever been arrested? |
Yes |
No |
If yes, provide: Date(s):
Reason(s):
Outcomes:
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:
Page 2 of 8
APPLICANT’S FINANCIAL INFORMATION
Receive Financial Assistance: |
Yes |
No |
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If yes, type: |
SS (Social Security) |
SSI (Supplemental Social Insurance) |
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VA (Veteran’s Benefits) |
Child Support |
Other |
If other, document type:
Does applicant have Title 19? |
Yes |
No |
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Does applicant have Medicare? |
Yes |
No |
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Does applicant have private insurance? |
Yes |
No |
APPLICANT’S HEALTH/MEDICAL INFORMATION
Current Medication(s) or can attach current medication orders or MAR:
Name
Dose
Frequency
Reason for Taking |
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Prescribed By |
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Does the applicant require assistance/supervision when taking medications? |
Yes |
No |
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If yes, describe the assistance/supervision required? |
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Allergies: |
Yes |
No |
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If yes, describe the assistance/supervision required? |
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Diet: |
Yes |
No |
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If modified or other, lit the type of diet ordered and reason: |
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Physical disabilities that require the use of adaptations (e.g. AFOs {braces}, orthopedic shoes, cane, walker, wheelchair,
etc.) |
Yes |
No |
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If yes, list adaptive equipment: |
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Seizures: |
Yes |
No |
History of |
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If yes or history of, describe type and frequency: |
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Vision Problems: |
No |
Yes – correctable with glasses |
Yes – but chooses not to wear glasses |
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Yes - uncorrected |
Blind Comments: |
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Hearing Problems: |
No |
Yes – correctable with hearing aides |
Yes – but chooses not to wear hearing aides |
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Adapt by others speaking louder |
Deaf |
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Comments: |
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Page 3 of 8
Skill Checklist: (please check items which best describe applicant)
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EATING |
Consistently |
Sometimes |
Never |
Comments |
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Completely independent
Needs assistance
Needs to be fed
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DRESSING |
Consistently |
Sometimes |
Never |
Comments |
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Completely independent
Needs assistance
Needs to be dressed completely
GROOMING |
Consistently |
Sometimes |
Never |
Comments |
Completely independent |
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Needs complete assistance |
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Bathes self with supervision |
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Bathes self independently |
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TOILETING |
Consistently |
Sometimes |
Never |
Comments |
Independent |
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Independent with reminders
Wears briefs
Toileting schedule
Indicates need to toilet / be changed
Incontinent during day
Incontinent during night
Females (cares for self during menstrual cycle)
COMMUNICATIONS |
Consistently Sometimes Never Comments |
Understands communication |
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Does not understand communication
Verbal communication
Speech easily understood
Communicates with gestures
Communicates with signing
Communicates with pictures
Communicates with verbal output assistance
Follows simple directions
Answers questions
Page 4 of 8
SOCIAL RELATIONS |
Consistently Sometimes |
Never Comments |
Accepts supervision |
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Enjoys interaction with peers
Involves self near, but not with others
Disrupts group activities
Makes close friends
Needs close supervision (about every five minutes)
Needs 1:1 supervision
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CHORES & ACTIVITIES |
Consistently |
Sometimes |
Never |
Comments |
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Helps with household tasks
Does routine chores
Goes about neighborhood without supervision
Makes purchases
Enjoys community activities
Uses public transportation
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HUMAN SEXUALITY |
Consistently |
Sometimes |
Never |
Comments |
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Demonstrates knowledge of own sexuality
Demonstrates knowledge of others sexuality
Masturbates in areas of home
Masturbates in public
Actively displays interest in opposite or same sex
Sexually Active
Displays sexually inappropriate behavior
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BEHAVIOR |
Consistently |
Sometimes |
Never |
Comments |
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Becomes upset when redirected/corrected
Demands excessive attention from others
Depressed
Complains of being persecuted
Pretends to be ill
Page 5 of 8
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 towards others
Physically aggressive towards objects
Tears clothing
Steals other’s belongings
Elopes/runs away from home
Uses tobacco
Uses alcohol
Uses other drugs
Removes clothing in public
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
Page 6 of 8
Completed by: |
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Applicant Name: |
Date: |
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Case Manager Name: |
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Date: |
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Parent/Guardian Name: |
Date: |
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Name/Title: |
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Date: |
Please return form to: REM Iowa (please check website for current contact information @ www.remiowa.com)
or send to REMIowaReferral@thementornetwork.com
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