Fillable Application For Services CRS AL 2021 Fillable PDF (Accessible Space)

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Application For Services CRS AL 2021 Fillable PDF (Accessible Space)

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Page 1 of 5
Customized Living and Community Residential Services
Request Form
Date of Application:
Individuals Name:
Date of Birth:
Gender:
Phone:
Address:
MA #:
Other Insurance:
Social Security number:
Gross Monthly Income:
Monthly Spend down:
Individuals Email:
Diagnosis:
Onset Date:
Height:
Approximate weight:
Description of injury or condition:
Emergency Contact Name:
Emergency Contact Phone, E-mail:
County Waiver Type
☐ CADI ☐ BI
☐ EW ☐ Other (what)
☐ Private Pay
County of Financial Responsibility:
Guardian/Conservator/Power of attorney: ☐ Yes ☐ No
Must Provide legal documentation (Please attach)
In the event that we are not able to reach the applicant who may we contact:
Name:
Phone:
Relationship:
Email:
Currently living in a health, nursing rehab facility, or group home: ☐ Yes ☐ No
Facility Name:
Facility Address:
Fax or Email Filled out form to Jody Parsons IHS Manager at 651-757-3036
jparsons@accessiblespace.org along with CSSP, IAPP, and other relevant records
Page 2 of 5
Facility Contact Name:
Telephone Number: Fax Number:
•
Assisted Living (own
apartment):
Consumer self-
directed services for persons
with a physical disability and/or
a BI or similar cognitive
disability in an apartment setting
with access to staff 24 hours per
day.
24-Hour
Assisted
Living (own
apartment)
24-Hour
Assisted
Living
(
shared
house)
Community
Residential
Services
(Corporate
Adult Foster
Care)
Check all that apply
☐Minneapolis
***
☐ Minneapolis
*
☐ St. Anthony
*
☐St. Paul
☐ Grand
Rapids *
☐ Falcon
Heights *
☐ Roseville *
☐ Coon Rapids
*
☐ New
Brighton **
☐ Blaine *
☐ Mounds
view **
☐ White Bear
lake *
☐ Champlain
**
☐ Brooklyn
Park **
☐ Rochester *
☐ Duluth *
For all locations you will also need to fill out a
housing application.
ASI housing application *
NHHI housing application **
SPPHA housing application ***
•
Assisted Living (shared house):
Consumer self-directed services
for persons with a physical
disability and/or BI or similar
cognitive disability in a shared
house with private bedroom,
access to staff 24 hours per day.
•
Community Residential
Services (Adult Foster Care
Home):
Supportive services for
persons with a physical
disability, BI and/or severe
cognitive disability in a shared
home with private bedroom.
Both asleep and awake overnight
staffing options.
Will anyone else be living with the applicant
☐ Spouse/Partner ☐ Children (age 17 or younger) ☐ Other adults
How Did you hear about us?
☐Web Site ☐ Case Manager___________☐ Family_______________☐ Other_______
Service needs (mobility)
☐ Ambulatory without aid
☐ Ambulatory with aid of device (what device)
☐ Manual wheelchair
☐ Power wheelchair
Page 3 of 5
Please check any of the following that you require assistance with. ASI does not
guarantee that all of these services are available through our service program.
Grooming Personal cares ADLs
☐Bathing ☐Oral Care (Including Dentures) ☐Dressing
☐Hair Care ☐Nail Care (Fingers/ Toes) ☐ Toileting (Including Bowel Program)
☐Skin Care ☐ Foot Care (Ointments, Lotions, Powders, Etc)
☐ Repositioning ☐Transfers (is a Hoyer or other mechanical lift needed needed?) ☐ Yes ☐ No
☐ROM I Exercise Program ☐ Mobility inside the Home ☐Opening Doors
☐ Eating/Drinking ☐Menu Planning ☐ Cooking
Supportive Needs CRS HOMES ONLY
☐ Retrieving Mail ☐ Organizing Mail ☐ Completing Forms/Applications
☐Set Up Household Budget ☐Assistance with Communication/Telephone
☐ Making Appointments ☐ Arranging Transportation
☐ Protecting Self from Abusive Situations ☐ Staff Support in Community/Escort Services
☐ Grocery Shopping
Vocational Needs
☐Identifying Volunteer Options ☐ Seeking Day Activities ☐ Finding Employment
Social Skills
☐ Cues/Prompting to Initiate Tasks ☐ Maintaining Appropriate Social Behavior
☐Maintaining Verbal Appropriateness ☐ Maintaining Appropriate Sexual Conduct
☐ Controlling Physical Aggression
☐ Maintaining Sobriety ☐ Following Directions
Health
☐ Medication Management (☐set up, ☐pass, ☐reminders) ☐ Applying Topical Medications
☐ Wound Care ☐ Monitoring Blood Sugar ☐ Self-Injections
☐ Catheter or Colostomy Care
☐ Other /Please List)
Page 4 of 5
Case Management Information:
Name:
Address:
Phone:
Fax
Email
Do you have any of the following?
Relocation service coordinator: ☐ Yes ☐ No
Name and phone number of that provider.
ARHMS or Mental Health Case Manager: ☐ Yes ☐ No
Name and phone number of that provider.
Individualized Home Support: ☐ Yes ☐ No
Name and phone number of that provider.
Personal Care Services ☐ Yes ☐ No
Name and phone number of that provider.
Housing History
Setting Codes (1) With Parent (2) Rental house, or apartment (3) Hospital (4) Group Home
(5) Nursing Home (6) Rehab Facility
Current Housing Code:
Former Housing code:
Length of residency:
Length of residency:
Name of facility/property:
Name of facility/property:
Reason for moving:
Reason for moving:
Medical History
List Hospitals, Rehabilitation Centers, Nursing Homes, etc. from which you have
received recent medical treatment.
IMPORTANT! Please fill out a corresponding
"Authorization for Release of Protected Information" form (attached) for each
vendor/provider/contact you list below.
Dates of Stay:
Dates of Stay:
Page 5 of 5
Facility Name:
Facility Name:
Address:
Address:
Phone:
Phone:
Fax:
Fax:
Primary Physician
Facility Name:
Address:
Phone:
Fax:
Psychiatrist Name
Facility Name:
Address:
Phone:
Fax:
Psychologist Name:
Facility Name:
Address:
Phone:
Fax:
* ASI uses race, ethnicity for grant writing purposes
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Application For Services CRS AL 2021 Fillable PDF (Accessible Space)

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Completed 2 August 2021

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