Intake Form Intake Form Scroll to the bottom and click save and continue for later if you would like to come back later to finish this form.Patient Name(Required) First Last Patient Phone(Required)Patient Email Patient Address(Required) 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 Are you the patient?(Required) Yes No Your Name First Last Your PhoneYou Email 1) Family HistoryFather First Middle Last CityStateStatus Living Died (Date) Date MM slash DD slash YYYY Current Contact None Occasional Daily Weekly Monthly Holidays Mother First Middle Last CityStateStatus Living Died (Date) Date MM slash DD slash YYYY Current Contact None Occasional Daily Weekly Monthly Holidays How Many Children Do You Have?How Many Children Do You Have?012345Children First Middle Last CityStateStatus Living Died (Date) Date MM slash DD slash YYYY Current Contact None Occasional Daily Weekly Monthly Holidays Children First Middle Last CityStateStatus Living Died (Date) Date MM slash DD slash YYYY Current Contact None Occasional Daily Weekly Monthly Holidays Children First Middle Last CityStateStatus Living Died (Date) Date MM slash DD slash YYYY Current Contact None Occasional Daily Weekly Monthly Holidays Children First Middle Last CityStateStatus Living Died (Date) Date MM slash DD slash YYYY Current Contact None Occasional Daily Weekly Monthly Holidays Children First Middle Last CityStateStatus Living Died (Date) Date MM slash DD slash YYYY Current Contact None Occasional Daily Weekly Monthly Holidays Do you have step parents? Yes No Step-Parents First ggg Last CityStateStatus Living Died (Date) Date MM slash DD slash YYYY Current Contact None Occasional Daily Weekly Monthly Holidays How Many Siblings Do You Have?How Many Siblings Do You Have?012345Sibling First Middle Last CityStateStatus Living Died (Date) Date MM slash DD slash YYYY Current Contact None Occasional Daily Weekly Monthly Holidays Sibling First Middle Last CityStateStatus Living Died (Date) Date MM slash DD slash YYYY Current Contact None Occasional Daily Weekly Monthly Holidays Sibling First Middle Last CityStateStatus Living Died (Date) Date MM slash DD slash YYYY Current Contact None Occasional Daily Weekly Monthly Holidays Sibling First Middle Last CityStateStatus Living Died (Date) Date MM slash DD slash YYYY Current Contact None Occasional Daily Weekly Monthly Holidays Sibling First Middle Last CityStateStatus Living Died (Date) Date MM slash DD slash YYYY Current Contact None Occasional Daily Weekly Monthly Holidays How Many Step Siblings Do You Have?How Many Step Siblings Do You Have?01234Step-Sibling First Middle Last CityStateStatus Living Died (Date) Date MM slash DD slash YYYY Current Contact None Occasional Daily Weekly Monthly Holidays Step-Sibling First Middle Last CityStateStatus Living Died (Date) Date MM slash DD slash YYYY Current Contact None Occasional Daily Weekly Monthly Holidays Step-Sibling First Middle Last CityStateStatus Living Died (Date) Date MM slash DD slash YYYY Current Contact None Occasional Daily Weekly Monthly Holidays Step-Sibling First Middle Last CityStateStatus Living Died (Date) Date MM slash DD slash YYYY Current Contact None Occasional Daily Weekly Monthly Holidays Do you have a spouse? Yes No Spouse First Middle Last CityStateStatus Living Died (Date) Date MM slash DD slash YYYY Current Contact None Occasional Daily Weekly Monthly Holidays 2) Educational historyHighest level of education completedSelect Education LevelSome ElementaryElementarySome High SchoolHigh SchoolSome CollegeAssociate DegreeBachelor's DegreeGraduate or Professional DegreeOtherPrefer Not to Answer3) Work HistoryDescribe the most significant employment experience(s); volunteer positions)4) Criminal Justice HistoryDescribe any history that impacts the applicant’s life including current involvement in the criminal justice system, if applicable No history of involvement in the criminal justice system Has a history of involvement in the criminal justice system Declined to answer Indicated history of involvement in the criminal justice system but declined to provide any further information History of criminal justice involvement (list all arrests and incarcerations in order):5) Substance Abuse HistorySubstance Abuse History No history of substance abuse issues or concerns Declined to answer Indicated history of substance abuse issue/concerns but declined to provide any further information History of substance abuse With Alcohol Prescription drugs Over-the-counter legal drugs Illegal Drugs (specifiy) Other (specify) History Of Substance abuse treatment (list all treatments and hospitalizations in order) Illegal DrugsOtherlist all treatments and hospitalizations in order6) Primary LanguagePrimary LanguageSelect Primary LanguageEnglishSpanishCreoleFrenchGermanOtherOther7) Detector locationsLocation of smoke detector in applicants homeLocation of carbon monoxide detector in applicants home8) Informal Supports Family/friends/community – Identify the present informal supports applicant considers most significant to his/her life, the level of support and the activities the family is providing. Describe the family’s willingness and/or ability to continue with their support. (List name and relationship of applicable supports) How Many People Support You?How Many People Support You?0123NameAgeRelationshipSupport Activites Provided (finances, MD appointments, Medication presort)Support is intermittent/periodic consistent/ongoing emergency only NameAgeRelationshipSupport Activites Provided (finances, MD appointments, Medication presort)Support is intermittent/periodic consistent/ongoing emergency only NameAgeRelationshipSupport Activites Provided (finances, MD appointments, Medication presort)Support is intermittent/periodic consistent/ongoing emergency only 9) Health Care Proxy: Name, phone number addressDo You Have Power Of Attorney? Yes No Power of Attorney: Name:Relationship to applicantPhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Do You Have A Healthcare Proxy? Yes No Health Care Proxy NamePhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country 10) Formal SupportsFederal/State Agency Supports: List all State and Federal non-Medicaid services the applicant receives or will receive while on the waiver (e.g. Medicare services, VA, VESID, Office of Aging, etc). SSL Medicare SSDI SSA Medicare Part A Medicare Part B Managed Care Part D QMBY SLMBY VA Pension VA-Medical VA- Aide and Attendant Services Va Equipment HUD Section-8 Other-subsidized housing (specify) EPIC Other Pharmacy Program (specify) Food Stamps Office for the aging Meals-On-Wheels EISEP (specify) Other OFA (specify) Other (specify) Subsidized Housing: SpecifyOther Pharmacy Program: SpecifyEISEP: SpecifyOther OFAOther: SpecifyIf yes, please list monthly amounts11) TrustDoes Applicant Have A Trust? Yes No Name of trustPhoneAmount that goes to trust each month12) DoctorsPrimary Physician NamePhoneEstimated Number Of Visits Per YearPhysician's (click the plus to add more)Physician name/SpecialityPhoneEstimated Number Of Visits Per Year Add RemoveDentist NamePhoneEstimated Number Of Visits Per Year13) Medication ListMedications (click the plus to add more)Medications (prescription and over the counter)DosagePurposeName of Prescribing Doctor Add Remove14) Pharmacy What is the name and phone number of the pharmacy the applicant uses? Pharmacy namePhone15) Hospital In case of emergency, which hospital would applicant prefer to use? Hospital Name16) Service AnimalDoes The Applicant Use A Service Animal? Yes No Type of service animalWhere does the animal recieve care/treatment, if needed?Where is the service animal boarded if participant is hospitalized?17) Medicaid/Medicare InfoMedicaid Effective Date MM slash DD slash YYYY Medicare Date MM slash DD slash YYYY CAPTCHA Δ
