Day Program Application

PARTICIPANT INFORMATION

First Name*

Last Name*

Preferred Name

Date of Application*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Is applicant a Medicaid recipient, or eligible recipient?*

Medicaid #*

Gender

FAMILY DATA

Parent or Guardian First Name*

Parent or Guardian Last Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Home Phone

Work Phone

Cell Phone

Emergency Contact Name*

Emergency Contact Relationship*

Emergency Contact Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact Home Phone

Emergency Contact Work Phone

Emergency Contact Cell Phone

REFERRAL DATA

Company

Case Manager/Contact Person Name

Referral Person's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Referral Person's Email

Referral Person's Main Phone

Referral Person's Relationship to Participant

Other (Please Specify)

CURRENT SERVICES RECEIVED

Services Currently Received

Please select all services which are currently being received.

DIAGNOSIS - DSM V

Axis I - Primary Diagnosis

Clinical disorders, including anxiety disorders, mood disorders, schizophrenia and other psychotic disorders.

Axis I - Primary Diagnosis 1

NAME	NUMBER	TYPE

Axis I - Diagnosis 2

NAME	NUMBER	TYPE

Axis II - Personality Disorder

Axis II - Diagnosis 1

NAME	NUMBER	TYPE

Axis II - Diagnosis 2

NAME	NUMBER	TYPE

Axis III - General Medical Conditions

These 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 - Diagnosis 1

NAME	NUMBER	TYPE

Axis III - Diagnosis 2

NAME	NUMBER	TYPE

Axis IV - Psychosocial and Environmental

These include conditions or situations that influence the diagnosis, treatment, or prognosis of the patient's mental disorder.

Axis IV - Diagnosis 1

NAME	NUMBER	TYPE

Axis IV - Diagnosis 2

NAME	NUMBER	TYPE

Axis 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 - Diagnosis 1

NAME	NUMBER	TYPE

Axis V - Diagnosis 2

NAME	NUMBER	TYPE

IDD LEVEL (Please provide a response for each level and select N/A if it does not apply)*

	MILD	MODERATE	SEVERE	PROFOUND	N/A (Not Applicable)
At Risk
Autism
Blindness
Cerebral Palsy
Deafness
Developmental Delay
Emotional
Hearing Impaired
Learning Disability
Orthopedic Impairment
Visual Impairment
Speech Impairment
Seizure
Other

IQ*

Other Diagnosis

Describe Physical Impairment

Describe Applicant's Ability to:

Date of Last Psychological Evaluation

Measured Full Scale IQ

Examiner's Name

Current Residential Status*

Please Specify Group Home

Please Specify Family Health Care Home

Please Specify Other

Current Day Placement Status

Please Specify Other

Assistance Needed

What Type of Assistance Is Needed?

Skill:	What Type of Assistance Is Needed?

Socialization and Communication

Socialization*

Initiates interaction with people
Initiates interaction selectively with familiar people
Interacts with peers, staff, and family
Interacts with staff, but not with peers, and family
Never or rarely interacts with staff, peers, and family

Expressive Communication*

Uses expressive language clearly
Uses expressive language with difficulty
Uses expressive communication acts
Uses augmentative communication
Uses vocalizations selectively
Does not intentionally express self
Uses ASL
Uses sign

Receptive Communication*

Comprehends most spoken language
Comprehends little spoken language
Responds to gestures or auditory cues
Attends to gestures or auditory cues
Does not respond to communication

Additional Comments Regarding Socialization and Communication

Mental Capabilities*

Has the applicant ever been treated by a psychiatrist/psychologist, state hospital, or mental health center?

Select One...
Yes
No

Please Explain and Include Dates of Treatment

Behavioral Habits

Describe any unusual or peculiar behavioral habits that UMAR should be made aware including sexual and psychological concerns.

Relational Ability with Others

Describe the applicant's ability to get along with others.

Physically or Verbally Aggressive?*

Select One...
Yes
No

Is the applicant physically or verbally aggressive?

Please Explain

Please include date of last aggressive episode.

Cognitive Ability

Describe the applicant's ability to remember, understand speech, and ability to think and respond.

Is the Applicant Aware of Time and Space*

Select One...
Yes
No

Physical Health Care

Does applicant have seizures?*

Select One...
Yes (If yes, Specify Type and Frequency)
No

Please specify type of seizures below*

Please specify frequency of seizures below*

Please List Any Known Allergies

Click the "+" sign to the right to add additional rows.

Current Health Status

Does applicant take medications outside of the home or during the day?*

Behavioral Concerns

Does the applicant display any of the behavioral concerns listed below? If yes, please rate severity accordingly. (Please provide a response for each level and select N/A if it does not apply)*

	1 = Mild	2 = Moderate	3 = Severe	N/A (Not Applicable)
Assultive
Cries/Screams Excessively
Damages Property
Eat Inedibles
Inappropriate Sexual Behavior
Lies
Loses Temper Easily
Low Tolerance to Being Physically Handled
Low Tolerance to Music
Low Tolerance to Taking Directions
Noncompliance
Self Injurious
Self Stimulation
Steals
Runs Away Purposely
Verbal Threats
Wanders Away Aimlessly

Explain All Above Rated Behaviors

Does the Applicant Display Any Form of Physical Aggression?*

Select One...
Yes
No

Please Explain

Social History

Education

Name	Location	Date

List Any Special Education or Training Including Art Education/Training

For Day Program or Supported Employment

List type of work and/or art experience.

List the Applicant's Strengths

List Cultural or Religious Preferences

Describe the Applicant's Challenges

Applicant Statement

Consent - Rules and Regulations*

I agree to the rules and regulations

I hereby apply for admission to the UMAR Services program. I agree to abide by the rules and regulations of the program and understand that violation of the rules can result in immediate suspension and/or discharge.

Consent - Drug Screening*

Drug Screening

If accepted, I agree that a drug screening may be required before entering a program at UMAR.

Consent - Criminal Background Check*

Criminal Background Screening

If accepted, I agree that a criminal background screening may be requested before entering a program at UMAR.

Consent - Acceptance of Use of Digital Signature*

Agree to Use of Digital Signature

By selecting this box, I accept the use of my personally typed name as my digital signature for this form.

Applicant's Digital Signature*

PLEASE NOTE

Before an application is accepted the following must be submitted to UMAR:
- Most recent psychological report
- Applicant's photograph
- Case manager's name and agency with contact information
- Current person centered plan (if applicable)
- Signed paperwork in addition to the application

Application for Day Programs

PARTICIPANT INFORMATION

FAMILY DATA

REFERRAL DATA

CURRENT SERVICES RECEIVED

DIAGNOSIS - DSM V

Axis I - Primary Diagnosis

Axis II - Personality Disorder

Axis III - General Medical Conditions

Axis IV - Psychosocial and Environmental

Axis V - Global Assessment of Functioning (GAF Score)

Socialization and Communication

Physical Health Care

Behavioral Concerns

Social History

Applicant Statement

PLEASE NOTE