Rem Iowa Service Application Form PDF Details

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.

QuestionAnswer
Form NameRem Iowa Service Application Form
Form Length5 pages
Fillable?Yes
Fillable fields165
Avg. time to fill out34 min 19 sec
Other namesrem iowa employee portal, TOILETING, amazon, rem application

Form Preview Example

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

 

 

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

No

Personality Disorder:

 

 

 

 

 

 

Yes

No

Schizophrenia or Schizoaffective Disorder:

Yes

 

No

 

 

 

 

 

Other Diagnosis:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LEGAL GUARDIANSHIP STATUS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does this applicant have a guardian?

 

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

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

1st Opening

Shelby

Washington

Coralville

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cedar Rapids | Marion | Hiawatha

No preference

 

 

 

 

 

3.

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

 

 

 

 

 

 

 

 

 

 

4.

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.

Page|1 of 5

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

No

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

Page|2 of 5

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:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICANTS FINANCIAL INFORMATION

 

 

 

 

 

 

 

 

 

 

 

Receive Financial Assistance:

 

 

 

Yes

No

 

 

 

 

 

 

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

No

 

 

 

 

 

 

Managed Care Organization (MCO)?

Amerihealth Caritas

Amerigroup

United Health

Optum N/A

 

 

Does applicant have Waiver funding?

Yes

No

 

 

 

 

 

 

Does applicant have Habilitation funding?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does applicant have private insurance?

Yes

No

 

 

 

 

 

 

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

Yes

No

 

 

 

 

APPLICANTS 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

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portion of fields in rem iowa application

Enter the requested details in the space IC, FID Yes, No, Relationship Email, Level, of, Care hour, Waiver, Adult hour, Habilitation Host, Home Unknown, Council, Bluffs, Only, Shelby st, Opening, Cedar, Rapids, Marion, Hiawatha Washington, Coral, ville No, preference and Waiver, Services

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