Start Services

Client Name*

First Last

Diagnoses

Date of Birth*

Gender*

Address*

Street Address Address Line 2 City State ZIP Code

Legal Parent / Guardian*

First Last

Email*

Phone*

Split Home

(parents / guardians live in separate homes)

Primarily Language / Cultural Considerations

Services Information

Support Coordinator Name

First Last

Support Coordinator Email

Support Coordinator Direct Phone

Service(s) Needed*

Habilitation
Respite
Attendant Care
Individually Designed Living Arrangement (IDLA)

Habilitation Hours Approved Weekly

Respite Hours Approved Weekly

Provider*

Client Basic Health

Is client visually impaired?*

If yes, details:

Is client hearing impaired?*

If yes, details:

Is client physically impaired?*

If yes, details:

Allergies

Medication / Supplement Name

Dosage

Frequency / Schedule

Medication / Supplement Name

Dosage

Frequency / Schedule

Medication / Supplement Name

Dosage

Frequency / Schedule

Infection Disease

Explain: (Details Here)

Hospitalization, Operations, Other Medical Conditions

Explain: (Details Here)

History of Seizures

Explain: (Details Here)

Dietary Restrictions

Dietary Considerations

Food Selectivity
Food Refusal
G-Tube
Requires Supplemental Nutrition (i.e. PediaSure)

Adaptive Devices*

Augmentative and Alternative Communication (AAC) Device
Ankle Foot Orthodontics (AFOs)/Leg, Foot or Ankle Braces
Glasses
Hearing Aids
Wheel Chair / Walker / Forearm Crutches
Other
Not Applicable

If other, please describe:

Communication

How does your loved one currently communicate?*

Assistive Communication Device
Gesture
PECS
Sign Language
Verbal: Fill out next section
Other: Fill out next section
Not Applicable

If Verbal above, details here (estimate # of words)

If Other above, details here

Social and Play Skills

How does your loved one currently interact with peers?

Safety

Has the client worked on safety skills?*

If yes, please explain:

Gross and Fine Motor

Are there any moving or lifting concerns that the provider needs to be aware of?*

If yes, please explain:

Daily Living Skills

Dressing

Bathing and Grooming

Feeding

Toileting

Aims into toilet standing (boys)
Wipes self (girls wipe from front to back)
Zips front zippers
Buttons front buttons
Snaps front snaps
Washes and dries hands - as part of the toileting routine
Night-time trained

Behavioral Concerns*

Top 3 Areas of Concern*

If Other, details here:

Availability for Habilitation Services

Monday*

Tuesday*

Wednesday*

Thursday*

Friday*

Saturday*

Sunday*

Availability for Respite Services

Monday*

Tuesday*

Wednesday*

Thursday*

Friday*

Saturday*

Sunday*

If services are needed past 7:00pm, please explain:

Provider Preference*

Is a provider needed who can help with dispensing medication?*

Do you need a provider to transport the client?*

If yes, please explain:

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Habilitation & Respite Services

Services Information

Client Basic Health

Communication

Social and Play Skills

Safety

Gross and Fine Motor

Daily Living Skills

Availability for Habilitation Services

Availability for Respite Services

Quick Links

Contact Info