Community Living Intake/Application

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THE ABILITY CENTER of Greater Toledo

5605 Monroe Street Sylvania OH 43560

Phone: (419) 885-5733 V/TTY Toll Free: (866) 885-5733

www.abilitycenter.org

Bryan Office 1425 E. High Street, Suite 108

Bryan, OH 43506 Phone: (419) 633-1400

Toll Free: (855) 633-1400 Fax: (419) 633-1410

Housing Resource Center

Fax: (419) 517-1360

For Office Use Only

Date Sent: Date Received:

Emergency Contact:

SECTION A: APPLICANT INFORMATION

Name:

Address:

County:

City: State:

Home Ph: Cell Ph:

Email:

Birth Date:

Zip Code:

Gender:

SS# (last 4):

Disability:To help us better identify appropriate resources for you, please check what disability/disabilities you identify with. If you select multiple disabilities, please let us know what you consider to be your primary disability by circling that selection.

Alzheimer's DiseaseAmputationArthritisAutism Spectrum DisorderBack InjuryBlind/Visual ImpairmentCancerCardiac/CirculatoryCerebral PalsyCognitive/Developmental DisabilityCystic FibrosisDeaf/Hearing Impairment

DiabetesDown SyndromeEmotional/Behavioral DisabilityEndocrine/Metabolic ConditionEpilepsy

Head Injury (TBI)HIV/AIDSLearning Disability

Mental IllnessMultiple SclerosisMuscular-SkeletalNeurological Condition

Physical DisabilityRenal DiseaseRespiratory/Pulmonary ConditionSickle Cell AnemiaSpeech ImpairmentSpina BifidaSpinal Cord InjuryStroke

Other:

Primary Language:

Emergency Contact Phone:

ALS

Dementia

Fibromyalgia

Lymphedema

Neuropathy

Parkinson's

According the US Census Bureau, Race and Hispanic origin are two separate concepts in the federal statistical system. Hispanic is no longer considered a race but rather an ethnicity. Members of any race may be Hispanic. Source: US Census Bureau, Population Division, Social and Demographic Statistics. You may check more than one category, i.e. you can be both African-American, Hispanic ethnicity, female head of household and a handicapped person.

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How did you learn about us? (Check all that apply):

Race:

Education: (Please select highest level completed)

Special Education/Certificate8th Grade or LessSome High SchoolHigh School Diploma/GED

Trade/Vocational

Some CollegeAssociates Degree

Graduate Degree

Doctorate Degree

Employment: (Please select your current employment status)

Full TimePart TimeNot Employed/Seeking WorkNot Employed/Not Seeking Work

RetiredSheltered EmploymentSupported EmploymentTransitional

Ability Center Staff/Board MemberFamily or FriendFormer ConsumerMaterials/Brochures

Presentation/Info FairSelfService Provider (Please list below)Website/Social Media

A. White/Caucasian

B. Black, African American

C. American Indian / Alaska Native

D. Asian

E. Native Hawaiian other Pacific Islander

F. American Indian, Alaska Native and White

G. Black, African American and White

H. American Indian, Alaska Native and Black, African American

I. Asian and White

J. Multi-Racial

K. Other / Unknown

K. Female Head of Household

L. Handicapped Person

Race Hispanic Ethnicity

Would you like to receive our newsletter? Yes No

Are you/spouse a Military Veteran? If Yes, are you connected with the county Veterans Service office?Yes No Yes No

Are you registered to vote? If no, would you like assistance registering?Yes No Yes No

Do you need adaptive format? Yes No Type?

Other (Please list)

No Formal Schooling

Bachelor's Degree

Do you need assistance locating alternative housing that meet your needs?

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Current Housing:

Yes No

Is your current housing accessible?

Is your rent based on your income?

Rent House/ApartmentOwn HouseFamily

Group HomeAssisted LivingHomelessHotel

Marital Status:

Transportation: What type do you use? (Check all that apply):

MarriedLiving with Significant OtherSingle

Widow/WidowerSeparatedDivorced

TARPS/Ambulette ServiceFamilyFriends

Personal Vehicle

Cab/Uber/Lift

Healthcare:

MedicareMedicaid

Dental Insurance

Vision Insurance

VA BenefitsPrivate Insurance

Do you need a live-in caregiver?

Yes No

Yes No

Yes No

Nursing Facility / Rehab Center

If you are currently in a nursing facility/rehab, please provide the following information:

Name of Facility:

Date of Admission: Expected Date of Discharge:

Reason for Admission:

Other:

Do you feel you are at risk of entering a nursing facility? Yes No

Have you been in a nursing facility within the last 12 months? Yes No

TARTA

Which mobility device do you use? (Check all that apply):

3 or 4 Wheeled ScooterWalkerManual Wheelchair

Electric Wheelchair

RollatorCane

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Do you need any Durable Medical Equipment or Assistive Technology? (Check all that apply):

Hoyer Lift

Wheelchairs

Raised Toilet Seat

Hospital Bed

Other:

Rollator (4 wheeled walker w/seat)

Walker (with or w/out wheels)

Bath SeatCanes/Quad Canes

Do you need a Home Modification? (If more than one needed please rank 1-4; 1 being most important)

Ramp HandrailsLow-Rise Steps Grab Bars Other:

Do you need assistance in any of the following Activities of Daily Living?

Eating

Bathing

Transferring

Medication

Grooming

House Cleaning

Meal Prep

Laundry

Shopping

Toileting

Transportation

Dressing

Finances

Have you been hospitalized within the last 12 months? Yes No

Have you had more than 6 visits to the emergency room within the last 12 months? Yes No

Do you have any additional informal supports? (i.e. help from spouse, children, siblings, friends) Yes No

Do you currently receive assistance from anyone for the activities you checked above? Yes No

Have you had any falls within the last 3 months? Yes No

Name of Case Manager:

Passport (Area Office on Aging)

Ohio Home Care Waiver (ODJFS)Level 1 or Individual Options (IO) (County DD)

MyCare Ohio Buckeye (waiver)

Please check if you are receiving services from any of the following waiver programs:

MyCare Ohio Aetna (waiver)Hospice / Name of Hospice Provider:

Case Manager Phone #:

If you are receiving services from any of the above, have you requested assistance through this program? Yes No

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*Please Provide Monthly Income of Every Individual in Household:

Social Security Income or Railroad Retirement

Supplemental Security Income, AFDC, or Other Public Assistance

Interests, Dividends, Rental Income, Real Estate Income

Alimony, Child Support, Workers Compensation

Pension/Annuity/Retirement

Non-Farm Self-Employment

Other Income

Total Monthly Income

Wages, Salary, Tips, Commissions, etc

Farm Self-Employment

Total Annual Income (monthly income x 12)

VA Benefits

Monthly Amount Received

Relationship:

Age:Relationship:Name:

Age:Relationship:Name:

Age:Relationship:Name:

Age:Name:

Age:Relationship:Name:

Age:Relationship:Name:

Names of Other Adults and Children Living In the Home

Income

If you are applying for a Home Accessibility Project you must include proof of all income claimed on this form. All household residents must indicate the type and amount of income received. Grants are based on gross income. Acceptable Proof of Income Documentation:

Last Three Consecutive Pay Stubs Latest Award Letters from Social Security Alimony Printouts from Issuing Agency

Signed Statement from Employer Record of Bank Deposit Signed Zero Income Statement from Consumer

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The Ability Center's mission is to create communities where everyone can live work and socialize independently and seeks to empower and enable individuals with disabilities, particularly individuals with significant disabilities, to exercise full choice and control over their lives. The purpose of this portion of the application is to capture the goals you wish to achieve while working with The Ability Center. In doing so, an Independent Living Plan will be developed to assist in tracking the progress of accomplishing these goals.

The following Goal Descriptions pertain to the reason why I am requesting assistance from The Ability Center. Check all that apply. To increase my:

Access to Community Based Living (to leave a nursing facility/institution or prevent placement in a facility/institution)

Ability to sustain independent living in my current home.

Home safety and to reduce falls within my home.

Access to healthcare services (rehab, therapy, dialysis, pharmacy, medical appointments).

Access to Transportation services (TARPS/DD/AOoA/School/Cab)

Access to Employment

Access to friends, family, neighbors, church, or other Social events.

Freedom of Choice and Opportunity.Ability to represent myself and have a sense of Empowerment.

Other

Access to a Benefit, Program, Service, or Activity.

Date Date

Signature of Applicant or Guardian ACT Staff Member

By signing below, I agree that the information included in this application is correct and that I identify as an individual with a significant disability.

Yes. I would like for the goals listed above to be incorporated into my Independent Living Plan.No. I waive my right to develop an Independent Living Plan.

What are your goals? Please list them below:

The Ability Center's funding sources require that we verify whether or not you are current with your property taxes. The Ability Center cannot process applications from homeowners with overdue taxes!

SECTION B: HOME ACCESSIBILITY PROJECTS ONLY

Do you own your home?

How long have you lived here?

How long do you plan on remaining at this address?

Number of bedrooms:

Building Type (Check one):

Yes No

Apartment ComplexDuplex Trailer (provide proof of Title if own)Single Family

Does your wheelchair/scooter clear the doorway?

It is the policy of The Ability Center of Greater Toledo to provide equal employment and promotion opportunities and services to all persons without regard to race, creed, color, citizenship, sex, age, national origin, religion, sexual orientation or disability. The Center operates and administers its programs and services without discrimination in the provision of those services. Additionally, The Center fully subscribes to the principles and intention of the Americans with Disabilities Act (ADA), which prohibits discrimination against persons with disabilities and expects all employees to support these principles as well.

How wide is your wheelchair or scooter from widest points? Measure precisely. This measurement ensures that your ramp is wide enough for your mobility device.

NoYes

Which door would you prefer to use for your project?: GarageRearSideFront2nd Choice: Front Side Rear Garage

Consumer Living Arrangement AgreementWhen applying for a ramp or home modification The Ability Center asks that you remain at this address for at least one year from the date of this agreement. By signing below you are agreeing that you intend to live there for at least one year from the date of this agreement.

Consumer Signature Date Signed

Parent / Guardian Signature Date Signed

Landlord/Apartment Manager, Home Owner, or Mobile Home Park Manager Information (as applicable)

Zip Code:State:City:

Address:

Name:

H Phone: W Phone:

Photos of the project will be taken for grant purposes. Would you consent to The Ability Center also using the photos for marketing purposes?

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If you need more than one modification, please rank 1-4; with 1 being the most important)

Ramp HandrailsLow-Rise Steps Grab Bars Other:

Yes No

SECTION C: DURABLE MEDICAL EQUIPMENT and ASSISTIVE TECHNOLOGY ONLY

In the event we are unable to loan or gift an item of DME, we will evaluate current grant funding to possibly assist in obtaining the items you need.  The information requested below must be collected when seeking such funding. In order to expedite your request for DME, please provide this information at the time of your initial application.

1. Prescription/Order for all requested durable medical equipment and services that require a prescription by law.

2. Statement or invoice for service or equipment from the vendor which you are seeking.

3. Proof of payment from another agency/organization or payment plan for items exceeding Ability Center's $300 ILA Grant.

Assistance or Item Needed:

Request: Cost:

Company:

Phone:

Office Use Only

Total Income:

Guideline:

Approved Denied

Applicant Signature Date

By signing this application, you are indicating that the above information you supplied is correct, and you have given The Ability Center your permission to contact the vendor of the requested item or service.

Physician's Information (Only if purchasing medical equipment that requires a prescription)

Physician:

Phone: Fax:

Comments:

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