Rem Iowa Service Application Form – Fill Out and Use

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		REM Iowa website			The MENTOR Network website
Hospital	REM Employee		Other Provider			County Case Manager
Other
If other, please document from whom/where:
APPLICANT INFORMATION
Applicant’s Full Name:
When Desired:	Next Available	Placement in Jeopardy				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			Intellectual Disability/ID:		Yes	No
Other Diagnosis:
LEGAL GUARDIANSHIP STATUS
Does this applicant have a guardian?			Yes	No
Name of Guardian:				Relationship:
COUNTY OF LEGAL SETTLEMENT/ FINANCIAL RESPONSIBILITY
County of Financial Responsibility:					Case Manager Name:
Telephone Number:					Email:
IME Determination Date:					Level of Care:

SERVICE(S) DESIRED

Type of Services Desired:		ICF/ID	24-hour Waiver (Adult)		Host Home		RBSCL
		24-hour Waiver (Children)		24-hour Habilitation		Vocational		Unknown
Communities desired:
1.	Children ICF/ID (ID must be primary diagnosis):			Council Bluffs Only
2.	Adult ICF/ID (ID must be primary diagnosis):			1st opening	Kalona		Shelby	Washington
				Coralville	Cedar Rapids | Marion | Hiawatha
				No preference

3.	Waiver Services:	1st Opening		Adel	Avoca	Atlantic	Davenport	Keokuk
		Cedar Rapids | Marion | Hiawatha				Harlan	Des Moines area	Ft. Madison
		Iowa City|Coralville			Shelby	Tipton	Mt. Pleasant	Mt. Vernon
		North Liberty			Council Bluffs		No preference
4.	Host Home
5.	Vocational:	Adel	Avoca		Hiawatha	Mt. Vernon
6.	Other community(s):

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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

Day/Vocational Services

Has the applicant ever been employed:

Yes

No

At a day program?

Yes

No

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:

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APPLICANT’S FINANCIAL INFORMATION

Receive Financial Assistance:	Yes	No
If yes, type:	SS (Social Security)		SSI (Supplemental Social Insurance)
	VA (Veteran’s Benefits)		Child Support	Other

If other, document type:

Does applicant have Title 19?	Yes	No
Does applicant have Medicare?	Yes	No
Does applicant have private insurance?		Yes	No

APPLICANT’S HEALTH/MEDICAL INFORMATION

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

Does the applicant require assistance/supervision when taking medications?			Yes	No
If yes, describe the assistance/supervision required?
Allergies:	Yes	No
If yes, describe the assistance/supervision required?
Diet:	Yes	No
If modified or other, lit the type of diet ordered and reason:

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:

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

	EATING	Consistently	Sometimes	Never	Comments

Completely independent

Needs assistance

Needs to be fed

	DRESSING	Consistently	Sometimes	Never	Comments

Completely independent

Needs assistance

Needs to be dressed completely

GROOMING	Consistently	Sometimes	Never	Comments
Completely independent
Needs complete assistance
Bathes self with supervision
Bathes self independently
TOILETING	Consistently	Sometimes	Never	Comments
Independent

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

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

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SOCIAL RELATIONS	Consistently Sometimes	Never Comments
Accepts supervision

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

	CHORES & ACTIVITIES	Consistently	Sometimes	Never	Comments

Helps with household tasks

Does routine chores

Goes about neighborhood without supervision

Makes purchases

Enjoys community activities

Uses public transportation

	HUMAN SEXUALITY	Consistently	Sometimes	Never	Comments

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

	BEHAVIOR	Consistently	Sometimes	Never	Comments

Becomes upset when redirected/corrected

Demands excessive attention from others

Depressed

Complains of being persecuted

Pretends to be ill

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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

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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

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