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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 Length7 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 45 sec
Other namesrem iowa application, Marion, rem iowa jobs, ICF

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

 

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):

 

 

 

 

 

 

 

Page 1 of 8

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

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

APPLICANTS 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

APPLICANTS HEALTH/MEDICAL INFORMATION

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

Name

Dose

Frequency

Reason for Taking

 

Prescribed By

 

 

 

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:

 

 

 

 

Page 3 of 8

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

Page 4 of 8

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

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:

 

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 7 of 8