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New Enrollment Packet
Magnolia Specialized Services, Inc. (870)-234-6118 or (870)-234-4118
_____Physical Examination
_____Prescription for Services
_____Psychological
_____Emergency Medical and Field Trip Release
_____Face Sheet
_____Social History
_____Diploma
_____Application for Services
_____Copy of Medicaid Card
_____Legal Guardianship
New Enrollment Packet
Medical Necessity Statement
Due to this person’s medical necessity, I hereby prescribe the following service/services for_________________________ (Individual’s Name)
Day Habilitation – DDTCS
Evaluation
Transportation
____________________________ ____________ Physician’s Signature Date
____________________________ _____________ Physician’s Name Provider Number
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Physical Examination
Name: _______________________ Date: _____________General Appearance: _________________________________________Height_____ Weight_____ Pulse_____ Resp_____ B/P_____ Temp______Check “normal” findings with “O”. Check “abnormal” findings with “X”.Describe the abnormal findings in the space at the right.
1. ____Head2. ____Eyes (including vision as best can be determined)3. ____Ears (whisper voice 10 feet)4. ____Nose 5. ____Throat6. ____Teeth7. ____Mouth8. ____Neck9. ____Chest and Lungs10.____Breasts11.____Heart12.____Abdomen 13.____Genitalia and Rectum14.____Pap Smear15.____Back, Bones, Joints, and Extremities 16.____Skin, Lymphatic, Hair17.____Muscular18.____Nutrition
Neurological
19.____Cranial20.____Cerebellum21.____Sensory22.____Motor23.____Operations24.____Other Findings25.____Person’s health and medical condition explained to person
Diagnosis________________________________________________________Medications_______________________________________________________Recommendations___________________________________________________Physician’s Signature______________________________________
Emergency Medical and Field Trip Release
New Enrollment Packet
I give my permission to go on field trips planned by the Verbie Graney CARC Center as part of the regular curriculum (Pizza Inn, Bowling, Library, etc.).
Signature of Individual: ___________________
Parent of Guardian: ______________________(If applicable)
In case of medical emergency requiring more attention than normal first aid, please take me _________________________ to Doctor ____________________________. If this doctor is not available, use Doctor ___________________________.
Signature of Individual: __________________________.
Parent of Guardian: _____________________________.(If applicable)
Date: ____________Witnessed by: _____________________
New Enrollment Packet
Individual Face SheetName: ____________________________ Social Security #: _______________Address: ____________________________ Telephone #: __________________ Cell Phone #: __________________ Date of Birth: __________________Sex: __________ Race: ____________ Legal Status: ___________________Marital Status: _______________ Parent Guardian Name: _____________________Address: _______________________________________ Telephone #: __________________
Emergency Contact Name: _______________________________(Other than listed above)Relationship: _______________________________Address: _______________________________ Telephone #: __________________
Health Insurance & Number: ___________________________________________Admission Date: _____________ Primary Language: ____________Primary Handicapping Condition: ___________________________________Secondary Handicapping Condition: __________________________________Physician’s Name: ___________________________Address: ____________________________________ Telephone #:_________________Current Medications & Dosage: ____________________________________________________________________________________________________________________________________________________________Allergies/Dietary Restrictions: ___________________________________________________
New Enrollment Packet
Case Manager: _________________________________ Date: ____________
Case Manager: _________________________________ Date: ____________
Case Manager: _________________________________ Date: ____________
Social History
Applicant: _____________________ Date: __________Address: _______________________ _______________________________Phone #: _______________________DDS SC: _______________________
I. Physical Description (General Description)
Marital Status: ________________________ Hair Color: ____________Height: ______________________ Eye Color: _____________Weight: _____________________ Race: ________________
II. Diagnosis (Check and complete appropriate blanks)
_____ Developmental Delayed_____ At risk for delay due to medical condition (identify condition) _________________________________________________________ Mental Retardation (Level if known) __________________________________ Epilepsy _____________________________________________ Seizures (type/frequency) _______________________________________
New Enrollment Packet
_____ Cerebral Palsy (functioning level if known) ______________________________ Autism (functioning level if known) ____________________________________ Adaptively eligible ___________________________________________________ Other, Please explain ____________________________________________
III. Services Requested and Current Situation
a. What assistance is needed and why? ____________________________________________________________________________________________________________________________________
b. Does individual presently reside with family? (If no, please explain.)____________________________________________________________________________________________________________________________
(III. Continued)c. Is present living situation satisfactory? (if not, please specify)
____________________________________________________________________________________________________________________________________
d. List agencies, schools, programs, etc., presently assisting applicant and services provided: ______________________________________________________________________________________________________________________________________________________________________________________________________
IV. Give the names, addresses, and phone numbers for the following:
Pediatrician __________________________________________________________Family Doctor ________________________________________________________Dentist ______________________________________________________________
New Enrollment Packet
Nurse _______________________________________________________________Orthopedist__________________________________________________________Ear, nose, and throat specialist _________________________________________Ophthalmologist _____________________________________________________Psychiatrist/Psychologist ______________________________________________Audiologist __________________________________________________________Speech Therapist _____________________________________________________Occupational Therapist ________________________________________________Physical Therapist ____________________________________________________Social Worker ________________________________________________________Dietician ____________________________________________________________Others (please specify) ________________________________________________
List any other agencies, programs, services considered, but not used, and reasons not used. __________________________________________________________________________________________________________________________________________List other agencies, schools, training facilities, and programs that have assisted applicant in the past, and services they provided. __________________________________________________________________________________________________________________________________________
(IV. Continued)Any past services requested from DDS or other agencies, and whether or not services were received, if not, why? __________________________________________________________________________________________________________________________________________
New Enrollment Packet
V. Family InformationFather
Name: ______________________ SSS: ______________________ DOB: ________Address: _________________________________________ Phone: ____________Deceased ______ Retired _______ Disabled _______Military: Active _______ Retired_______ Branch________Employer: ______________________________________ Phone: ______________Salary Estimate: _______________________________________
MotherName: ______________________ SSS: ______________________ DOB: ________Address: _________________________________________ Phone: ____________Deceased ______ Retired _______ Disabled _______Military: Active _______ Retired_______ Branch________Employer: ______________________________________ Phone: ______________Salary Estimate: _______________________________________
Does applicant have any income? (If yes, how much and what type?)__________________________________________________________________________________________________________________________________________
List Children Age Child Income Source Payee_______________ ______ ____________ __________ ___________________________ ______ ____________ __________ ___________________________ ______ ____________ __________ ____________
Please list AFDC, VA, SSI, SSA, Child Support, Trust, and PayeeType Amount Individual Payee________________ _________ _____________ _____________
New Enrollment Packet
________________ _________ _____________ _____________________________ _________ _____________ _____________
(V. Continued)List any other close family members: _______________________________________________________________________________________________________________________________________________________________________________________________________________
VI. Developmental/Behavioral Profile
Answer appropriately (yes or no and list age)
Yes No Age Yes No AgeSat Alone ____ ____ ____ Toilet Trained ____ ____ ____Crawled ____ ____ ____ Bowel ____ ____ ____Walked Alone ____ ____ ____ Bladder ____ ____ ____Made sound/ babble
____ ____ ____ Dry at Night ____ ____ ____
Single word ____ ____ ____ Pronounced Clear ____ ____ ____Phrases/Sent. ____ ____ ____ Understood by mom ____ ____ ____Says Words Correct ____ ____ ____ Understood by others ____ ____ ____
Areas of Concern
____ Walk ____ Dress Self ____ Prepare Own Needs____ Talk ____ Write/Print ____ Bathe/Groom Self____ See ____ Tell Time ____ Travel Alone____ Hear ____ Use Toilet ____ Work Independently____ Read ____ Feed Self ____ Wash Clothes____ Recognize Money ____ Self-medicate____ Communicate ____ Use Telephone
Behavioral Profile
Does Applicant have challenging behavior/temper tantrums? (Explain)____________________________________________________________________________________________________________________________________________________________
New Enrollment Packet
Behavioral Profile (cont.)
Describe applicant’s typical behavior with regard to:Activity Level
___________________________________________________________Aggressive or
Passive_____________________________________________________Reactions to
others_______________________________________________________
Describe any unusual/extreme behavior of applicant (and frequency) with regard to:
Reaction to authority ____________________________________________________________________________________________________________________________________________________________Non-compliant/oppositional behaviors (if yes, explain/describe) ____________________________________________________________________________________________________________________________________________________________Possible injurious episodes (if yes, explain/describe) ____________________________________________________________________________________________________________________________________________________________Any self-stimulatory behaviors (describe) ____________________________________________________________________________________________________________________________________________________________
VII. Medical History
A. Birth Information
Problems during pregnancy (explain) _______________________________________Length of pregnancy _______________ Labor induced/delayed _________________Medications taken during pregnancy _______________________________________Did mother smoke ___________ Drink _______________ Drugs ______________Did father smoke ____________ Drink _______________ Drugs _______________
New Enrollment Packet
List infections: Mother ___________________________________________________ Father____________________________________________________Birth Weight ________________ APGAR ____________________________________Complications __________________________________________________________Hospital _________________________________ Length of Stay _________________
B. Individual’s Information
Has the applicant been tested for hearing? __________________________________If yes, when? _________________________ Where? ___________________________What were you told? _____________________________________________________Medical History (cont.)
Current Medications (type & dosage) ________________________________________________________________________________________________________________________________________________
Check all that apply:_____ Asthma/respiratory problems_____ Allergies_____ Infections_____ High Fever (104+), duration_____ Operations (including tubes in ears)_____ Special diet needs (if any)_____ Other health concerns or needs/childhood diseases (specify) ________________________________________________________________________________________________________________________________________________
Medical Procedure Needs (list any special requirements on the right)
_____ Catherization Provider _____________________________________________________________________________________________________________________________________________________ Hyper alimentation Provider ________________________________________________________________________________________________________________________________________________
New Enrollment Packet
_____ Injections Provider _____________________________________________________________________________________________________________________________________________________ Intervenous Provider_____________________________________________________________________________________________________________________________________________________ Respiratory Care _____________________________________________________________________________________________________________________________________________________ Suctioning Provider _____________________________________________________________________________________________________________________________________________________ Tracheotomy Care _____________________________________________________________________________________________________________________________________________________ Tube Feeding Provider ________________________________________________________________________________________________________________________________________________
VIII. Person- Centered Planning Information
Preferred activities (games, toys, etc.) ______________________________________________________________________________________________________________________________________________________
How does the applicant get along with other people? ____________________________Children? __________________________ Adults? ________________________________
How does the applicant usually react to separation from parent or caregiver, or familiar surroundings? ______________________________________________________________________________________________________________________________________________________
What goals would you like to see the applicant achieve? ______________________________________________________________________________________________________________________________________________________
How can the family/friends/others help? ______________________________________________________________________________________________________________________________________________________
New Enrollment Packet
How do you feel the agency can help? ______________________________________________________________________________________________________________________________________________________
_____________________________ _________________ Informants Signature Date
_____________________________ Relationship to Applicant
Services Needed/Recommended:
A brief statement of the service coordinator/program staff’s assessment of the individual, family’s needs. Include options discussed with individual, family, or concerned party.
Recommendations of service(s) needed to assist the individual and who might provide the services, with time frames, if appropriate.
Comments: (attach other pages if necessary)______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
New Enrollment Packet
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________ ________________ DDS Service Coordinator/Program Staff Date
Department of Human ServicesDivision of Developmental Disabilities Services
Application for Services
Date of Application _______________Applicant’s Name ______________________________________________Applicant’s Address ____________________________________________________________________________________________________________________________________________________________County __________________Telephone # ___________________________________Legal Status ___________________________________Applicant’s Social Security # __________________________________Applicants Medicaid # _______________________________________Applicants Medicare # _______________________________________Insurance Company Name and # ____________________________________________________________________________________________________________________________________________________________
S.S.I. Recipient
New Enrollment Packet
Yes No
Social Security Disability
Yes No
Name of Parent/Guardian _______________________________________________________
Address ____________________________________________________________________________________________________________________________________________________________
County ________________ Telephone ____________________________________________
Application for Services (cont.)
Relationship __________________________________________________________________Work Address _________________________________________________________________Work Telephone # _____________________________________________________________Directions ____________________________________________________________________________________________________________________________________________________________
Primary Disability _____________________________________________________________Secondary Disability ___________________________________________________________
Applicant’s Physician ___________________________________________________________
New Enrollment Packet
Physicians Address ____________________________________________________________________________________________________________________________________________________________Telephone # __________________________________________________________________Services Requested ____________________________________________________________________________________________________________________________________________________________
Emergency ContactName___________________________________________________________Address ____________________________________________________________________________________________________________________________________________________________Telephone # __________________________________________________________________
Referred by: ____________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________ Signature of parent or guardian
________________________________________________ _________________ Relationship Date
New Enrollment Packet
________________________________________________ _________________ Witness Date(If person is not incapacitated but unable to sign due to physical disability)
Unless the person is legally incapacitated, he/she must sign this form. If he/she is legally incapacitated, it must be signed by the personal guardian (accompanied by proof of guardianship). If person is not incapacitated but unable to sign because of physical disability, his/her mark or consent must be witnessed.
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