Residential Services Application Step 1 of 5 20% This application takes 1-2 hours to complete. Please be sure that you have all of your documentation at the time of starting the application and complete in one sitting. IS UMAR A FIT FOR ME? UMAR serves adults with a PRIMARY DIAGNOSIS of intellectual and developmental disabilities (IDD). In order to qualify to receive our services, the applicant's IQ cannot exceed 70. If you meet both of the above criteria, we encourage you to apply for our residential, day, and/or vocational services.After submitting the application, you will be required to upload the following materials within 48 hours: - Recent psychological report - Applicant photograph - Medical history - Behavioral evaluations/modification plans (if applicable) - Current service plan (if applicable) If you have any technical issues, please contact marketing@umarinfo.com.Person submitting application* First Last Relationship to Applicant Resident InformationName* First Middle Last Preferred Name Gender*Select...MaleFemaleDate of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*Type of Placement*Select...Licensed HomeApartmentWhich area are you applying for?*Select...AshevilleCharlotteConcordCorneliusGastoniaGreensboroHayesvilleHigh PointLincolntonStatesvilleWinston-SalemOther (Specify Below)Which area are you applying for?*Select...CharlotteCorneliusHuntersvilleOther (Specify Below)If you selected 'Other', please explain What has caused you to seek residential placement at this time?* Please identify services that are needed for the applicant to stay in his/her residential placement.* Family Contact InformationParent Name* First Middle Last Parent Email* Parent Home/Cell Phone*Parent Work PhoneParent Address (If different from above) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact* First Last Emergency Contact Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact Email Emergency Contact Home Phone*Emergency Contact Work PhoneReferral DataCase Manager/Other Individual Agency Name (if applicable) Program or Contact Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Relationship to Applicant*Select...ParentLegally Responsible PersonGuardianOther (Specify Below)If you selected 'Other', please explain Legal Guardianship StatusLegal Guardian Name First Middle Last Type of Guardianship (If Applicable) County of Adjudication Date of Adjudication MM slash DD slash YYYY Legal Guardian Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Legal Guardian Email Legal Guardian Home PhoneLegal Guardian Work Phone Diagnoses - DSM VAxis I - Primary DiagnosisClinical disorders, including anxiety disorders, mood disorders, schizophrenia and other psychotic disorders.Axis I - Primary Diagnosis 1NAMENUMBERTYPEAxis I - Primary Diagnosis 2NAMENUMBERTYPEAxis II - Personality DisorderAxis II - Primary Diagnosis 1NAMENUMBERTYPEAxis II - Primary Diagnosis 2NAMENUMBERTYPEAxis III - General Medical ConditionsThese include diseases or disorders that may be related physiologically to the mental disorder; that are sufficiently severe to affect the patient's mood or functioning; or that influence the choice of medications for treating the mental disorder.Axis III - Primary Diagnosis 1NAMENUMBERTYPEAxis III - Primary Diagnosis 2NAMENUMBERTYPEAxis IV - Psychosocial and EnvironmentalThese include conditions or situations that influence the diagnosis, treatment, or prognosis of the patient's mental disorder.Axis IV - Primary Diagnosis 1NAMENUMBERTYPEAxis IV - Primary Diagnosis 2NAMENUMBERTYPEAxis V - Global Assessment of Functioning (GAF Score)Assessed level of functioning is intended to help the doctor draw up a treatment plan and evaluate treatment progress.Axis V - Primary Diagnosis 1NAMENUMBERTYPEAxis V - Primary Diagnosis 2NAMENUMBERTYPEIdentify Support Needs (Check all that apply) At Risk Deafness Social/Emotional Hearing Impairment Physical Impairment Seizure Disorder Speech Impairment Visual Impairment Vocational Services Other (Specify Below) If you selected 'Other', please explain* IQ* Please describe any physical impairments (vision, speech, hearing, etc.)*Please describe applicant's ability to walk, stand, bend, sit up, an use arms, legs, and hands*Date of Last Psychological Evaluation* MM slash DD slash YYYY Examiner* Physical Health CarePreferred Physician First Name Last Name Preferred Physician Address Street Address Phone City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred Dentist First Name Last Name Preferred Dentist Address Street Address Phone City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred Hospital Hospital Name Preferred Hospital Address Street Address Phone City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code List any hospitalizations within the last five years (Please use the + button to list multiple occurences)DateReasonLocation List all immunizations, screenings, drug sensitivities, or any medical issues we should know about (Please use the + button to list multiple)DateTypeNotes Level of Intellectual Disability*Select One...MildModerateSevereProfoundDoes applicant have seizures?*Select One...Yes (Please Specify Type and Frequency)NoPlease specify type of seizures below*Select One...Absence Seizures (aka petit mal)Tonic-Clonic (aka grand mal)Atonic Seizures (aka drop attacks)Clonic SeizuresTonic SeizuresMyoclonic SeizuresPlease specify frequency of seizures below*Select One...DailyWeeklyMonthlyYearlyNot within the last two yearsList any allergies (Please use the + button to list multiple allergies) Is the applicant currently on any prescribed medications?*Select One...YesNoMedications (Please use the + button to add multiple medications)*Medication NameDosage and FrequencyRoutePurpose of MedicationCompliance Issues Self-Administration of Medications*Select...Able to take medications in the right doses at the right timeCan take medications, needs help with preparationCan prepare and take medications with reminderUnable to take medications without assistanceMental HealthHas the applicant ever been treated by a psychiatrist/psychologist, state hospital, or mental health center? (Please explain and include dates)* Describe any unusual or interfering behavior habits that UMAR should know about (sexual, behavioral, and psychological concerns)* Describe the applicant's ability to get along with others* Is the applicant physically or verbally aggressive? (If so, please explain and give date of last aggressive episode)* Describe the applicant's ability to remember, understand speech, and ability to think and respond.* Is applicant aware time and place?*Select...YesNoDoes applicant sign his/her own name on legal forms and checks?*Select...YesNoVision, Hearing, and DentalCorrective Lenses*Select...GlassesContact LensesNoneVision*Select...Normal VisionSome DifficultyGreat DifficultyLegally BlindTotally BlindUndeterminedLeft Eye Vision_____ /20Right Eye Vision_____ /20Hearing Level*Select...No Hearing LossMild Hearing LossSevere Hearing LossProfound Hearing LossUndeterminedHearing Aid*Select...YesNoDental HealthSelect...Good Dental HealthIn Need of Dental ServicesNo Dental ServicesDental Appliances*Select...Yes (Specify)NoIf you selected 'Yes', please explain: Additional Comments Regarding Vision, Hearing, or Dental Current Applicant ServicesCurrent Funding Services Received* Select all that apply... State Funding Community Living and Support Community Networking Innovations Waiver Supported Employment None Other (Specify Below) If you selected 'Other', please explain* Current Residential Services*Select...AFL HomeCommunity Living and Supports HomeFamily Care HomeICF-MRInstitution (Specify Below)Nursing HomeOwn HomeParents' HomePsychiatric HospitalRest HomeSupervised Living HomeSupported LivingOther (Specify Below)If you selected 'Institution' or 'Other', please explain Date Admitted (If Applicable) MM slash DD slash YYYY Date Discharged (If Applicable) MM slash DD slash YYYY Program Name Program PhoneProgram Director Program Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Day Placement Services*Select...SchoolSupported EmploymentCompetitive EmploymentDay ProgramVolunteerNoneOther (Specify Below)If you selected 'Other', please explain Duties/Responsibilities Date Admitted/Hired MM slash DD slash YYYY Date Discharged/Resigned/Terminated (If Applicable) MM slash DD slash YYYY Program Name Program PhoneProgram Director Program Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Independent Living AbilitiesDressing Skills (Select all that apply)* Independently Dresses Self Requires Verbal Prompting Requires Physical Assistance Toileting Skills* Independently Uses Restroom Requires Verbal Prompting Requires Physical Assistance Sleeping Habits* Sleeps Through the Night Has Sleep Disturbances Interests* Television Music Outdoor Activities Privacy Social Groups Sports Swimming Movies Games Community Involvement Other (Specify Below) If you selected 'Other', please explain Supervision* Unsupervised Time in Home/Community Requires Supervision at all Times Leisure Skills* Entertains Self-Determination Needs Guidance from Others Socialization* Initiates Interaction with Others Initiates Interaction with Familiar People Never or Rarely Interacts with Staff, Peers, and Family Expressive Communication* Uses Expressive Language Clearly Uses Expressive Language with Difficulty Uses Expressive Communication Gestures Uses Augmentative Communication Uses American Sign Language Receptive Communication* Comprehends Most Spoken Language Comprehends Little Spoken Language Responds to Gestures or Auditory Cues Does Not Respond to Communication Does the applicant display any of the following behaviors? If so, please rate the level below.*Not an IssueMildModerateSevereCries/Screams ExcessivelyExcessive AngerExcessive LyingHistory of Running AwayInappropriate Sexual BehaviorPhysically AssaultivePICA/Attempts to Eat InediblesProperty DamageSelf InjuriousSelf StimulationStealsVerbally AssaultiveBehaviorPlease explain any behaviors above rated Moderate to Severe List the applicant's strengths (Please use the + button to list multiple strengths)* List the applicant's challenges (Please use the + button to list multiple challenges)* Social HistoryEducationWhereWhen Special Education or TrainingWhereWhen Residence History*CityCountyStateDates What are the family's plans for future involvement?*What are the family's plans if trial placement is unsatisfactory?*How does the applicant feel about living in a group home?* Financial InformationIncome (SSI, Social Security, Employment, Etc.)*Source of IncomeMonthly Amount Does applicant have an Innovations Waiver*Select One...YesNoNot SureIs applicant his/her own payee?*Select...YesNo (Specify)If you selected 'No', please explain* Property - Please list description and locationReal EstateReal Estate ValueOther PropertyOther Property Value Savings Accounts, Stocks, Checking AccountsAccountValue Insurance InformationIs applicant a Medicaid recipient, or eligible recipient?*Select One...YesNoMedicaid Number* Is applicant a Medicare recipient, or eligible recipient?*Select One...YesNoMedicare Number* Does the applicant have private insurance?*Select One...Yes (If yes, please provide insurance information)NoPrivate Insurance Information Company Name Company Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Policy/Group Holder Name Subscriber ID/Group Number Number of Policies CertificationUMAR prohibits the use of illegal drugs or other criminal activities. Do you engage in illegal drug use or other criminal activity?* Yes No By checking the boxes below, I certify that all pertinent information regarding behavioral problems, sexual problems, psychological problems, drug use, criminal activity, and any incidents that have occurred in these areas have been given to the admissions committee. No information has been withheld. I hereby give my consent for release of all medical information and social, vocational, and psychological evaluations as needed to the UMAR Admissions Committee for the purpose of determining eligibility for placement in UMAR Services, Inc. I also understand that a drug and criminal check may be performed prior to admission.* Applicant Agrees Witness (Parent or Guardian) Agrees Applicant StatementI hereby apply for admission to the UMAR Residential Program. I agree to abide by the rules and regulations of the home and understand that violation of the rules can result in discharge.* Applicant Agrees Witness (Parent or Guardian) Agrees Required File UploadsThe following materials are required within 48 hours of submitting your application: - Recent psychological report - Applicant photograph - Medical history - Behavioral evaluations/modification plans (if applicable) - Current service plan (if applicable) If you have any trouble uploading the files, please mail copies to the following address: UMAR Services, Inc. Attn: Admissions 5350 77 Center Drive, Suite 201 Charlotte, NC 28217 Email to: umaradmissions@umarinfo.comFile Upload Drop files here or Select files Accepted file types: jpg, pdf, Max. file size: 1 MB. Δ
