Preliminary Application for Services Waiting List

Bittersweet Farms

Preliminary Application for Services
The following information will be used as a tool to assess service interests and placement on the waiting lists at Bittersweet Farms. Bittersweet will be in contact for additional information when the applicant’s name is up for review for an opening in their chosen programs. Please complete this application as fully and accurately as possible.
Today's Date

MonthDayYear
Date
Basic Information
Name of individual*

First NameMiddle NameLast Name
Date of birth*

MonthDayYear
Date
Age*
Place of birth*
Is the individual a US citizen?*

YesNo
Current address*

Street Address

Street Address Line 2

CityState

Zip Code
In what COUNTY do you reside?*
Telephone
If you are your own guardian, please provide your phone number.
Email
If you are your own guardian, please provide your email address..
Gender

MaleFemaleOther
Height*
Weight*
Hair color*
Eye color*
Identifying marks, if any
Age where developmental delay first noticed*
Date Autism Spectrum Disorder officially diagnosed*

MonthDayYear
Date
Complete list of diagnoses.*
Please initial you understand that failure to disclose all diagnoses may lead to a 30 day notice to discontinue services.*

Clear
Guardian Information
Is the person their own guardian? If yes, proceed to Family History section.*

YesNo
Name of guardian (probate court appointed for those 18 years and older)

First NameLast Name
Guardian's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian's telephone
Please enter a valid phone number.
Guardian's email
example@example.com
Guardian's relationship to applicant
Guardian's employer
Guardian's employer telephone
Please enter a valid phone number.
Family History
Mother's name

First NameMiddle InitialLast Name
Father's name

First NameMiddle InitialLast Name
Mother's address if different from applicant or father

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's telephone
Please enter a valid phone number.
Mother's email
example@example.com
Father's address if different from applicant or mother

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's telephone
Please enter a valid phone number.
Father's email
example@example.com
How does the individual get along with:
Mother*
Father*
Siblings*
Emergency Contact

(in addition to parents/guardian)
Name of emergency contact*

First NameLast Name
Relationship of emergency contact to individual*
Emergency contact's primary phone number*
Please enter a valid phone number.
Emergency contact's secondary phone number*
Please enter a valid phone number.
Medical History
Name of primary physician*

First NameLast Name
Primary physician's address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary physician's telephone*
Please enter a valid phone number.
Name of dentist*

First NameLast Name
Dentist's address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of specialist*

First NameLast Name
Type of specialist
Specialist's address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Medications*
Allergies (food, medication, animals, seasonal, other)*
Do any allergies require use of EpiPen? If yes, list those allergies here.
Preferred OTC medications*

TylenolAdvilAleveAspirinOther - please list
Date of last physical*

MonthDayYear
Date
Current health*
Any current medical concerns*
Special diet instructions*
Please list dates and reasons for any surgeries*
Adaptive equipment*
Physical limitations*
Personal History

Education

	Name and address	Dates attendeed
School 1
School 2
Graduated from

Latest Employment

	Name and address	Dates employed
Employer 1
Employer 2

Any previous residential placement and reason for transfer*
Has the individual ever plead guilty or “ no contest ” to a crime or been convicted of a crime ( felony or misdemeanor ? ) and or have criminal charges pending?*

YesNo

Sources of additional information (any professional, specialist or agency not previously listed who may be able to provide information about the individual)

	Name	Phone	Contact person	Type of services provided
1
2
3
4

Please mark the service(s) the individual would like to receive:*

Adult Residential - ICF/DD - WhitehouseAdult Residential - Community Living Whitehouse (waiver funded)Adult Residential - HUD Housing/BRK Community Living Whitehouse (waiver funded)Adult Residential - Pemberville (waiver funded)Adult Residential - Whitehouse Women's Home (waiver funded)Adult Day Program - Whitehouse (waiver funded)Adult Day Program - Lima (waiver funded)Transition School (12 to 21 years of age) - PembervilleSummer Enrichment (12 to 21 years of age) - Whitehouse/Pemberville (private pay only, scholarships available)Social Recreation Program (12+ years of age) - Whitehouse/Lima (private pay only, scholarships available)
* If applicant selected HUD Housing, please report annual income

Funding Sources

	Currently have	Currently applying	Not as this time
Medicaid
Medicare
Level 1 Waiver
Individual Options (I.O.) Waiver
Private Pay

Other funding sources
County Support
Name of county caseworker

First NameLast Name
Caseworker's telephone
Please enter a valid phone number.
Caseworker's email
example@example.com
Date ready to begin services*

MonthDayYear
Date
Signature
Where did you hear about Bittersweet Farms?
Please provide your email*

Confirmation Emailexample@example.com
Signature of person completing form*

Clear
Signature date*

MonthDayYear
Date
Relationship to applicant*
For questions related to this application, contact us at 419-875-6986 ext. 1230 or info@bittersweetfarms.org.

When you have submitted the application successfully, you will see a "Submitted Successfully Checkmark" verifying that Bittersweet Farms has received your application.
Please verify that you are human*
Should be Empty:

Bittersweet Farms

Basic Information

Guardian Information

Family History

How does the individual get along with:

Emergency Contact

Medical History

Personal History

County Support

Signature