Application for Services

Date of Application *

Check the program(s) for which the application is being submitted.

ADULT SERVICES *Residential ServicesRespite CarePersonal SupportsDay Service

Applicant's General Information

First Name *

Middle Name

Last Name *

Date of Birth *

Place of Birth *

Current Address:

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP *

# of years

Is your permanent address the same as your current address? *YesNo

Permanent Address:

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP *

# of years

County *

County of Interest *

Telephone # *

Social Security # *

Type of Income/Amount

Medical Assistance #

Medicare #

Other Health Insurance

Prescription Coverage *

Does Applicant have a Service Coordinator?

Name of Service Coordinator

Phone of Service Coordinator

Parent/Guardian/Caregiver Information

Name *

Relationship to Applicant *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP *

Phone Number *

Cell Phone Number

Email Address *

May we send you information via e-mail? *YesNo

Applicant's Living Situation

Please include names

Parents

Guardian or Relatives

Foster Home

Other

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal code *

Phone Number *

Legal Guardian *YesNo

Date Guardianship was attained *

Number of occupants living in the home *

Family Information

Father:

Name

Birth Date

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal code

Country

Home Phone

Occupation

Work Phone

Work Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal code

Social Security #

Living/DeceasedLivingDeceased

If deceased, date

Place of Birth

Marital Status

Mother:

Name

Birth Date

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal code

Country

Home Phone

Occupation

Work Phone

Work Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal code

Social Security #

Living/DeceasedLivingDeceased

If deceased, date

Place of Birth

Marital Status

Brothers & Sisters:Must list, and include Name, Birth Date, Relation to Applicant, Phone Number and Occupation

Other Family Members Living in the HomeMust list, and include Name, Birth Date, Relation to Applicant, Phone #, and Occupation

Emergency Contact

Other than Parent/Guardian/Caregiver

Name *

Relationship to Applicant *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal code *

Country

Phone Number *

Applicants Financial Information

(If applying for Respite, do not complete this section)

SSI Claim #

SSI Amount

SSA Claim #

SSA Amount

Does Individual have an overpayment with Social Security?YesNo

If yes, why? (Please include letter from Social Security with explanation)

Name of wage earner

Is the parent a Veteran?YesNo

If yes, who?

Is either parent retired?YesNo

If yes, who?

Is either parent deceased?YesNo

If yes, who?

Name of Representative Payee

V.A. Claim #

V.A. Benefit Amount

Name of Veteran

Railroad Retirement Claim Number

Name of wage earner

Life Insurance Coverage

Burial Plot Location

Estimated value

Type of Burial Plan

Other sources of Applicant's Income

List all Bank Accounts that are held either solely by the applicant or jointly with another party. Attach copy of most recent statement(s).

Bank Name(s) and type of account:Please list here

Any property in applicant’s nameGive location and value

Trust FundYesNo

Type

If yes, give name and address of trustee

Applicant's place of employmentName and Address

Applicant's monthly earnings from employment

Attach copy of two most recent paystubs.

Medical Information

A. Applicant's primary health care provider/physician

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal code

Phone Number

Date of last physical exam

Examined by

Street Address

Hospital familiar with applicant (if any)

B. Diagnosis

Primary

Secondary

Tertiary

Age of Onset

C. Does applicant have a formal behavioral plan that agency developed?YesNo

Name of agency that developed the plan

D. List any medication(s) taken by applicantInclude medication, dosage, and reason

E. History of HospitalizationsInclude the Date, Reason, Hospital, and Physician

F. Seizures

1. Does the applicant have seizures?YesNo

2. FrequencyDailyWeeklyAt least once a monthEvery few months

3. Type of seizures

Are seizures controlled by medication?YesNo

G. Applicant's Mobility

Walks independentlyUses caneUses crutchesUses walker

Uses wheelchairYesNo

The wheelchair is:ManualElectricSelf propelled

H. Vision

1. Any vision impairment:YesNo

2. Does applicant wear glasses or contact lenses?

3. Date of last eye exam:

Legally Blind:YesNo

I. Hearing

1. Does applicant have a hearing problem?YesNo

2. Does applicant wear a hearing aid?YesNo

3. Date of last hearing exam:

Deaf:YesNo

J. Dental

1. Date of last dental exam:

DenturesYesNo

2. Brief description of any dental problem(s)

3. Is individual currently in need of any dental procedures?YesNo

Please include statement from dentist indicating general dental health.

No file chosen

K. Equipment Needed

CheckboxHoyer LiftBed RailsNeed for oxygen?Other adaptive / special equipment

Other adaptive / special equipment needed

L. Allergies(bee stings, drugs, dust, mold, food, etc.)

Does applicant have any other medical problems not listed?

Diet (chopped food, tube fed, finger foods etc.)

Speech and Language Information

1. Does applicant have a speech/language impairment:YesNo

2. Is applicant verbal?YesNo

3. Has applicant had a speech/language assessment?YesNo

4. Assessment done by:

5. Means of communication:SpeechSign LanguageGesturesCommunication Board

Mental Health

1. Does applicant have a history of mental health treatment, alcohol or substance abuse?YesNo

List previous treatment and dates:Please provide the Date, Treatment Center, In-Patient or Out-Patient, and Physician/Counselor

2. Is the applicant currently in treatment?YesNo

3. Name of psychiatrist/counselor

4. Diagnosis

Psychological Information

A. Date of last psychological evaluation:

Performed by:

Address

Diagnosis

B. Does applicant have a history of behavioral problems?YesNo

If so, describe the problem noting Behavior, Frequency, Severity, and Intervention

C. Has the applicant ever been convicted of a crime?YesNo

Provide details:

D. Is any other family member diagnosed as having a disability?YesNo

Describe

Background Information

Name of Schools AttendedPlease list and include Name of School, Complete Address of School, and Dates Attended for each.

Contact Person:

Adult Programs AttendedPlease list the Adult Programs Attended, Complete Address, and Dates Attended for each.

Contact Person:

Vocational Trainings or EvaluationPlease list the Vocational Trainings or Evaluation, Complete Address, and Dates Attended for each.

Contact Person:

Skills Checklist

A. Is applicant independent in personal self-care skills?(e.g. bathing, dressing, feeding, toileting)YesNo

Type of assistance needed with toileting:

Does (s)he prefer a bath or a shower?

B. Can applicant self medicate?YesNo

C. Can applicant cross streets?IndependentlyWith AssistanceNo

D. Can applicant use mass transit?IndependentlyWith AssistanceNo

E. Is applicant capable of remaining at home unsupervised?YesNo

If yes, how long?

F. Can applicant read?YesNo

What level?

G. Does applicant sleep through the night?YesNo

H. What time does the applicant usually go to bed?

I. What time does the applicant get up in the morning?

J. What does the applicant like to do in his/her free time?

K. Please provide a brief description of the applicant’s daily routine

Has applicant received or is receiving any type of services or financial assistance from Richcroft, Inc. or any other agency?(i.e. Rolling Access, Respite Services, In-Home Support, Foster Care etc.)YesNo

If yes, please list agency / agencies and explain in detail

Signatures

Signature of parent/guardian (if applicable)

Date

Signature of parent/guardian (if at least 18 years old)

Date

Signature of person completing this form

Date

Chesterwye Center, Inc. provides services and operates its facilities without discrimination on the basis of race, color, national origin, religion, political affiliation, marital status, age, sex or disability. The following information is useful for statistical purposes only; completion of this portion of this application is voluntary.

Religion:

Please specify

U.S. Citizen?YesNo

Sex:MaleFemale

Height:

Weight:

Eye Color:

Hair Color:

Language(s) spoken or understood:EnglishOther

Please specify

Language(s) used in Applicant’s home environment:EnglishOther

Please specify

Authorization to Obtain Information

Date authorization becomes effective:

Date

and expires on

Date

I,

hereby authorize

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal code

Phone Number

(specify)

to Chesterwye Center, Inc., 110 Chesterwye Lane, Grasonville, MD 21638

I understand that the information being requested will be used by Chesterwye Center Inc, Inc. to assist in determining the agency’s capacity to support me now and/or assist in planning with me for the future.

I understand that all information shared with Chesterwye Center, Inc. will be treated in a strictly confidential manner, and any further sharing of my information will require my additional authorization. I understand that authorization is extended for this request only and at this time only.

I understand that I have the right to revoke this authorization in writing at any time except to the extent that action on this authorization has already occurred (i.e. the information was already distributed).

Individual’s Signature

Date

Parent/Guardian (must sign if person is under 18)

Date

Witness (must sign if “X” is used)

Date

Relationship of Witness to Individual

Agency Representative

Date

Title of Agency Representative

Applicant/ Family Agreement

Name:

We understand and agree that:

1. We will be offered to participate in any program of family education.

2. Chesterwye Center, Inc. may take, publish, and exhibit photographs, videos, or work of the individual.

3. We hereby agree to absolve Chesterwye Center, Inc., employees, or the Board of Directors of the responsibility for accidents or injuries to the individual that may occur while occurring while in our care, with the exception to the extent that the accident/ injury is covered by the agencies insurance.

4. The individual will be allowed to accompany Chesterwye Center, Inc. on outings, excursions, and activities in connection with the Program, with the understanding the individual will be monitored by staff.

5. The Director and staff of Chesterwye Center, Inc. will make every effort to ensure the safety of all individuals while under the care of the agency.

Individual’s Signature:

Family/ Guardian Sign

Witness (Title):

Date

Option 1: Chesterwye Center Photo/Video Release Form

I hereby grant Chesterwye Center, its representatives, employees, and agents the right to take photographs, video recordings, or digital images of the person supported in connection with Chesterwye Center programs, services, or events. I authorize Chesterwye Center to copyright, use, and publish the same in print and/or electronically.

I agree that Chesterwye Center may use such photographs or recordings of the person supported with or without the person’s name and for any lawful purpose, including publicity, illustration, advertising, social media, and web content.

I understand that I will not receive any compensation for the use of these photographs, video, or digital images.

Signature of Person Supported /Guardian

Date

I DO NOT grant Chesterwye Center, its representatives, employees, and agents the right to take, use, or publish photographs, video recordings, or digital images of the person supported in connection with Chesterwye Center programs, services, or events.

I understand that Chesterwye Center will make every reasonable effort to ensure that the person supported is not included in photographs, videos, or digital images used for publicity, illustration, advertising, social media, or web content.

This non-consent will remain in effect until I provide written authorization otherwise.

Signature of Person Supported /Guardian

Date

I hereby grant Chesterwye Center, limited permission to take photographs, video recordings, or digital images of the person supported in connection with Chesterwye Center programs, services, or events. This permission is limited to use **only within the Group Home or Day Program setting**.

I understand that these photographs, video recordings, or digital images will be used solely for internal purposes within the Group Home or Day Program setting (such as activities, documentation, or in-home displays). They will NOT be used for external marketing, publicity, social media, website content, or advertising.

This limited consent will remain in effect until I provide written notice otherwise.

TextSignature of Person Supported /Guardian

Date

Needed Copies of Documentation

· Copy of Photo ID

· Copy of Social Security Card

· Copy of Birth Certificate

· Medical Insurance Information

· Guardianship Information (if applicable)

· Any court-order documents (if applicable)

Other information that will be needed prior to admission.

· Social Summary

· Education History

· Psychiatric Evaluation

· Medical Summary

· DDA Application for Eligibility

· Banking / ABLE accounts (Residential/ Personal Support Services)