New Hope Application for Services
Applicant Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Parent/Guardian
Parent/Guardian Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Placement Information
Lives At Home
Receives Services
Discharged from Current Services
If you selected Receives Services or Discharged from Current Services- Please provide us with the current Agency's information (Name & Address). If Discharged was selected- please provide a reason why.
Eligibility Information
Case Manager
Case Manager Email
example@example.com
Case Manager Phone
Please enter a valid phone number.
Type of Service Requested
Supported Community Living
ID Waiver
BI Wavier
Habilitation
Supported Employment
Day Habilitation
Prevocational Services
ICF/ID
Hourly
Daily
Funding Source
WP
ITC
DHHS
MHC
Private Pay
Other
Date Desiring Services
-
Month
-
Day
Year
Date
Current Diagnosis
Date of Last Psychological Evaluation
-
Month
-
Day
Year
Date
(Please include copy of evaluation if available)
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Hospitalizations (list dates and reason for any hospitalizations in the past year)
Describe Past Work Experience, if any
Data Collection Notification
The information we are requesting is essential for the proper management of the service you are applying for. If New Hope discovers that any information has been falsified or omitted, we reserve the right to deny services or, if you are currently receiving services, to consider discharge. Authorized personnel will only use the information collected for the purposes outlined here. Any other use of this information will not occur without your prior written consent, unless required by law. You also have the right to review the information this agency maintains about you.
Additional Material to Submit with this Application
Social Hisotry, Psychological Report or Assessment, Incident Report, SIS Assessment/Inter RAI, Guardian/Conservatorship Papers, Physcial Exam, Service/Behavir Plans, Medication List & Diagnosis, and any other pertinent information.
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General Admission Criteria
Must not have a felony conviction or be listed on the Sex Offender Registry· Must not require continuous 1:1 supervision· Must be able to regularly participate in daily activities and show progress or maintain skills · May require assistance but should be capable of learning and maintaining skills in mobility, self-help, communication, and leisure activities · If there is a history of seizure activity, it must be under moderate control · Must not have severe emotional, psychological, or behavioral issues. Severe aggressive, violent, or destructive behaviors, or behaviors that are criminal in nature, are not acceptable. Behaviors should not pose harm to the individual or others. Individuals requiring intensive use of restraints, time-out, or aversive techniques are not appropriate. Must not need intensive services for behaviors related to a psychiatric condition. New Hope will assess the behavioral and psychological needs of each individual to determine whether our services can effectively support those needs.
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