UMAR
  • Events
  • Residential Services
  • Vocational Services
  • Arts Centers
  • Donate Now
Select Page

Application for Day Programs

  • PARTICIPANT INFORMATION

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Please enter a number from 1 to 5.
  • FAMILY DATA

  • REFERRAL DATA

  • CURRENT SERVICES RECEIVED

  • Please select all services which are currently received or approved to receive.
  • Hidden
    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.
  • NAMENUMBERTYPE
  • NAMENUMBERTYPE
  • Axis II - Personality Disorder

  • NAMENUMBERTYPE
  • NAMENUMBERTYPE
  • 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.
  • NAMENUMBERTYPE
  • NAMENUMBERTYPE
  • Axis IV - Psychosocial and Environmental

    These include conditions or situations that influence the diagnosis, treatment, or prognosis of the patient's mental disorder.
  • NAMENUMBERTYPE
  • NAMENUMBERTYPE
  • 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.
  • NAMENUMBERTYPE
  • NAMENUMBERTYPE
  • MILDMODERATESEVEREPROFOUNDN/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
  • Please list any other diagnosis not previously mentioned above.
  • Describe Physical Impairment (Vision, Speech, Hearing, etc.)
  • Walk, Stand, Bend, Sit up, Use Arms, Legs, and Hands
  • MM slash DD slash YYYY
  • (Please select one...)
  • Skill:What Type of Assistance Is Needed? 
  • Socialization and Communication

  • Has the applicant ever been treated by a psychiatrist/psychologist, state hospital, or mental health center?
  • Describe any unusual or peculiar behavioral habits that UMAR should be made aware including sexual and psychological concerns.
  • Describe the applicant's ability to get along with others.
  • Is the applicant physically or verbally aggressive?
  • Include date of last aggressive episode.
  • Describe the applicant's ability to remember, understand speech, and ability to think and respond.
  • Physical Health Care

  • Click the "+" sign to the right to add additional rows.
  • Behavioral Concerns

  • 1 = Mild2 = Moderate3 = SevereN/A (Not Applicable)
    Assaultive
    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
  • Social History

  • NameLocationDate 
  • List type of work and/or art experience.
  • Applicant Statement


  •       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.

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

  •       If accepted, I agree that a criminal background screening may be requested before entering a program at UMAR.
  • By selecting this box, I accept the use of my personally typed name as my digital signature for this form.
  • 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
Save and Continue Later

Copyright ©2023 UMAR Services, Inc. | All rights reserved.