DATE OF APPLICATION ________________________

1. Name of person applying for admission to Residential Services Program:

__________________________________________________________

2. Applicant’s present address:____________________________________

___________________________________________________________

3. Telephone No.:______________ 4. Sex: M_____ F_____

5. Martial Status:_______________ 6. Date of Birth:________

7. Place of Birth:_______________ 8. US Citizen: Yes_____ No_____

9. Religion:___________________ Church Attended:________________

10. Has applicant been a resident of a Developmental Center or Psychiatric Center: Yes_____ No_____

If so, Facility:___________________________________________________

Date of Placement:__________________________________________

Primary Diagnosis:__________________________________________

County of Origin:____________________________________________

If several institutionalizations, list dates of all admissions and discharges: _______________________________________________________________

11. Does applicant have a Developmental Disability: Yes_____ No_____

Mental Retardation_____ Neurological Impairment_____

Cerebral Palsy _____ Epilepsy_____

From Birth: Yes_____ No_____

If no, please explain: ______________________________________________________________

12. Family Information:

Legal Guardian Yes_____ No_____

Address:_____________________________________________________

Phone Number:________________________________________________

Father’s Name:____________________________________________________

Address:_________________________________________________________

Home Phone:____________________Business Phone:___________________

Mother’s Name:___________________________________________________

Address:_________________________________________________________

Home Phone:____________________Business Phone:___________________

Sibling’s Name:___________________________________________________

Address:_________________________________________________________

Home Phone:____________________Business Phone:___________________

Sibling’s Name:___________________________________________________

Address:_________________________________________________________

Home Phone:____________________Business Phone:___________________

Family Arrangements: Yes_____ No_____

Cemetery Plot: ___________________________________________________

_______________________________________________________________

Funeral Home: ___________________________________________________

_______________________________________________________________

13. In case of Emergency, Notify:

________________________________________________________________

Name Phone Number

________________________________________________________________

Address Relationship

14. Has applicant ever attended school: Yes_____ No_____

If yes, Name of School:_____________________________________________

Date of Attendance: From____________________ To__________________

Highest grade achieved:______________________ Type of Class:

Regular:_____________

Special:_____________

15. Has applicant participated in a Day Treatment Program: Yes_____ No____

If yes, Name of Program:____________________________________________

Address:_________________________________________________________

Dates of Participation: From___________________ To__________________

Contact Person:_____________________________ Phone No.___________

16. Has applicant worked in a Sheltered Workshop: Yes_____ No_____

If yes, Name of Workshop:___________________________________________

Address:_________________________________________________________

Dates of Participation: From____________________ To_________________

Contact Person:______________________________ Phone No.__________

17. Has applicant ever been competitively employed: Yes_____ No_____

If yes, Employer:______________________________ Phone No._________

Address:________________________________________________________

Position Held:____________________________________________________

Dates of Employment: From_____________________ To_______________

Employer:___________________________________ Phone No.__________

Address:________________________________________________________

Position Held:____________________________________________________

Dates of Employment: From_____________________ To_______________

18. If applicant is not presently attending school or work program, how does he/she spend the day? _______________________________________

________________________________________________________________

19. Applicant’s Social Security Number: _____-_____-_____

Representative Payee:______________________ Phone No.___________

20. Does applicant receive Social Security (SSA) benefits:

Yes_____ No_____ If yes, monthly amount: $___________________

Social Security Number Collected On:______________________________

21. Does applicant receive Supplemental Security Income (SSI) benefits:

Yes_____ No_____ If yes, monthly amount: $___________________

22. Public Assistance: Yes_____ No_____ Monthly Amt. $_____________

23. Does applicant receive Veteran’s Benefits (VA)? Yes_____ No_____

If yes, Monthly Amount: $_____________ VA Number:________________

24. Railroad Retirement Benefits: Yes_____ No_____ Claim #___________

25. Is applicant on Medicaid? Yes_____ No_____

If yes, Medicaid Number:________________________________________

Effective Date:________________________________________________

26. Is applicant on Medicare (red, white, blue card)? Yes_____ No_____

If yes, Medicare Claim Number:___________________________________

Part A? Yes_____ No_____ Part B? Yes_____ No_____

Effective Date:_________________________________________________

27. Does applicant have private health insurance? Yes_____ No_____

If yes, Company:_______________________________________________

Policy Number:_______________________ Premium:_________________

28. Does applicant have any of the following?

Bank Account (s): Yes_____ No_____

If yes, 1. Bank:___________________________________________________

2. Bank:_____________________Acct. No.:______________________

Balance: $_____________________

Trust Fund: Yes_____ No_____

If yes, where held:_________________________ Balance: $______________

Stock Bonds: Yes_____ No_____ Current Value: $______________

If yes, Company:______________________ Face Value: $________________

Burial Fund: Yes_____ No_____

If yes, where held:____________________________ Balance:$____________

Life Insurance: Yes_____ No_____

If yes, Insurance Company:__________________________________________

Date of Issue:__________ Premium:__________ Face Value: $__________

Childhood Development/Conditions (Include Major Illnesses and Injuries):

_________________________________________________________

29. If applicant has a doctor:

Name:_______________________________________________________

Address:_____________________________________________________

Date of Last Exam:_____________________________________________

30. If applicant has a dentist:

Name:_______________________________________________________

Address:_____________________________________________________

Date of Last Exam:_____________________________________________

31. If applicant is seen by a Psychiatrist, Counselor or Mental Health Clinic:

Name:_______________________________________________________

Address:_____________________________________________________

32. If applicant has a physical handicap, describe:________________________

________________________________________________________________

33. Does applicant exhibit any inappropriate behavior please explain:_________

_______________________________________________________________

34. If applicant has a mental or emotional problem, describe:_______________

____________________________________________________________

35. Describe Specific Health/Nursing Needs:____________________________

________________________________________________________________

36. Has applicant ever been hospitalized: Yes_____ No_____

Reason:______________________________________________________

37. Has applicant ever had surgery: Yes_____ No_____

Reason:______________________________________________________

38. Does applicant have any allergies: Yes_____ No_____

Type of Foods:________________________________________________

Describe Reaction:_____________________________________________

Type of Medication:_____________________________________________

Describe Reaction:_____________________________________________

39. Does applicant have seizures: Yes_____ No_____ Type:____________

Describe Seizures:_____________________________________________

Medication Taken for Seizures:____________________________________

_____ Glasses _____ Dentures _____ Walker _____ Crutches

_____ Hearing Aid(s) _____ Wheelchair _____ Cane

_____ Other:_____________________________________________________

Regular or Other:__________________________________________________

________________________________________________________________

Hearing Assessment:______________________________________________

_______________________________________________________________

Visual:__________________________________________________________

Podiatry/Foot Care:_______________________________________________

_______________________________________________________________

GYN:___________________________________________________________

________________________________________________________________

40. Medication Taken By Applicant:

Medication:_______________________ Dosage:______________________

Time Taken:______________________ Reason:______________________

Physician:_______________________________________________________

Medication:_______________________ Dosage:______________________

Time Taken:______________________ Reason:______________________

Physician:_______________________________________________________

Medication:_______________________ Dosage:______________________

Time Taken:______________________ Reason:______________________

Physician:_______________________________________________________

Medication:_______________________ Dosage:______________________

Time Taken:______________________ Reason:______________________

Physician:_______________________________________________________

Medication:_______________________ Dosage:______________________

Time Taken:______________________ Reason:______________________

Physician:_______________________________________________________

41. Briefly describe applicant’s interests and hobbies:_____________________

________________________________________________________________

I hereby give authorization to the Arc of Oneida-Lewis Chapter, NYSARC, to release any information to qualified agencies or professionals who have a bonafide professional interest in me.

I also authorize the Arc of Oneida-Lewis Chapter, NYSARC, to secure information from other professionals, schools or agencies who have observed or provided me with services.

_____________________________________

Applicant’s Signature

_____________________________________

Signature of person filling out application

_____________________________________

Parent/Guardian Signature

_____________________________________

Date Signed