P.E.P. Center Intake Packet

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Please complete this form in its ENTIRETY!

If all fields are not filled out, we are not able to consider accepting your request to attend until these are filled out.

This is so that we can fully understand what the needs of the individual are, and how we can best serve them in working toward their goals.

Name of Individual wanting to attend *

Name of Person Filling out form (Also include your relation to the individual that will be attending, upon acceptance) *

Contact Phone Number *

Contact email *

Requested Start Date *

YYYY

Days Requesting to Attend (Check all that apply) *3 days per week minimum Requirement* *

Monday

Tuesday

Wednesday

Thursday

Friday

Required

Today's Date *

YYYY

Date of Birth *

YYYY

Current Age

Gender

Female

Male

Prefer not to say

Other:

Clear selection

Social Security Number (last 4 digits) *

State ID/Driver's License #

Current Address (Street # and Name, City, State, Zip Code) *

Type of Residence

Group Home

Apartment

Family Home

Own Home

Clear selection

Staffing in Home

Someone is with me at all times

Some is with me as needed

Someone checks in with me

Clear selection

Current Supports Coordinating Agency *

Goodwill

Community Living Services (CLS)

NSO

MORC

Guidance Center

Wayne Center

STEP

All Well Being

Support Coordinator (Name and Phone #)

Current Managed Care Provider

Community Living Services (CLS)

DWIHN (Detroit Wayne Integrated Health Network)

I am not with a Managed Care provider

Clear selection

Primary Diagnosis *

Secondary Diagnosis/Conditions

List Programs/Schools Attended by Individual for past 5 years *

List any Volunteer/Employment Placements within the last 2 years

Transportation Needs *PLEASE NOTE: this may or may not be available, SELECT ALL THAT APPLY! *

I can provide my own transportation to and from P.E.P.

I will need partial transportation to/from P.E.P.

I will need transportation to AND from P.E.P.

I would like to hear more about transportation options

Required

Describe Individual's Physical Needs (toileting, feeding, lifting, etc.) *

Describe Individual's Behavioral Support Needs *

I have no concerning behaviors and don't need help with self-control

I will need occasional gentle reminders to help with self-control

I will need help a couple times a day to help with self-control

I will need help several times a day to help with self-control

I will need someone sitting within arms length of me at all times to help me with self-control

Please what behavior(s) individual will need help to control: ______________________________________________________________________________________________________________________________________________________

Required

List individual's triggers to becoming upset and needing assistance

Describe how we can best help the individual when they are upset ?

List any allergies and how the person reacts when exposed to those allergens:

Select any Health Risks we need to monitor for *

Choking

Food Stealing

Elopement (leaving area of supervision)

Fecal Smearing

Anal Digging

Soiling ones self

Seizures

Other_________________________________________________________________________________

Required

Does the individual have seizures or take medication to control seizures?

Yes

IF yes, when was last seizure episode

If yes- describe what seizure episodes look like: _____________________________________________________________________________________________________________________________________________

Select all that apply and Describe individual's personal care ability (toileting, hand washing, sanitizing, general cleanliness/hygiene) *

I will ask for help with personal care/Let you know when I need to go

I will not ask for help with personal care

I need help sometimes with personal care.

I need help daily with personal care tasks.

If help is needed, list what and how often and what needs the individual has ______________________________________________________________________________________________________________________________________________________________________________________________

I don't need help, I can complete all personal care tasks independently

Required

Select all that apply and Describe individual's verbal communication preferences and abilities

I use verbal communication

I do not use verbal communication

I use a device to communicate with others (Please list device)

I use pictures to communicate with others

I use vocalizations to communicate with others

I use eye gaze to communicate with others

I need assistance communicating. Circle (Verbally, using a device, using pictures)

I can make choices using objects

I can make choices using pictures

Select all that apply and describe individual's ability to understand directions *

I can understand what you're saying, but may or may not follow your directions/respond

I can understand what you're saying and require time to process and respond

I can follow one step directions

I can follow two step directions

I can follow multi-step directions independently

Describe Prompting Style that works best Circle one: (Verbal, Gestures, Non-Verbal, Physical, Hand over Hand)

Required

Select all of the Prompting / Assistance styles that work best *

No prompting needed

Verbal (using word(s) to capture attention)

Gestures (pointing to choice/object, catching attention)

Physical (Guide/Support hand physically toward choices)

Hand over Hand (Physically support individual's hand to participate)

Required

List and describe ALL health conditions and Risks of Harm (i.e. eloping, fall risk, choking risk, skin breakdown risk, etc.) *

List all medications prescribed by a physician (include medication names and purpose below. PLEASE NOTE: Physician's orders/prescriptions are required for all medications to be administered by P.E.P. staff. ******MUST NOTIFY PEP OF ANY CHANGES TO MEDICATION WITHIN 24-48 HOURS OF DOCTORS CONSULTATION***** *

Signature ( I hereby certify that I have answered these questions truthfully and to the best of my ability) TYPE OR PRINT NAME to agree *

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