Crsrehab-SGHMMHC Form 1

CRSRehab-SGHMMHC Form 1

(Revised 12/2014)

RESTRICTED

Central Referral System for Rehabilitation Services
Subsystem for Small Group Home for Mildly Mentally Handicapped Children (CRSRehab–SGHMMHC)

Registration Form

I.Personal Particulars

1.Name:
(English) / (Chinese)
2.Sex: / MaleFemale
3.Date of Birth: / (dd) / (mm) / (yyyy)
4.HKBC/IC No.:
5.Residential District: /

Hong Kong and Islands

Central and WesternEasternSouthernWanchai

Islands

Kowloon

Kwun TongWong Tai SinKowloonCityMongkok

ShamshuipoYaumateiTseung Kwan OSai Kung

New Territories
Kwai TsingTsuen WanTuen MunYuen Long
Tin Shui WaiTai PoShatinMa On Shan
North (Sheung Shui and Fanling)

II.Disability

1.Physical disability / A: Physically disabled, please specify:
N: Not physically disabled
2.Spastic/cerebral palsy / A: SpasticB: Cerebral palsyN: Not spastic or cerebral palsy
3.Hearing / A: DeafB: Partially ImpairedN: Normal
4.Vision / A: BlindB: Partially ImpairedN: Normal
5.Mental disability / IQ score:
Date of psychological assessment: / (dd) / (mm) / (yyyy)
(please attached psychological report)
6.Mental illness / A: Mentally ill, diagnosis:
N: Normal
7.Speech / A: Speech disabledN: Normal
8.Autism / A: Autism as assessed by psychiatristN: Normal
9.Down's Syndrome / A: Downs SyndromeN: Not Downs Syndrome
10.Other Illness/disability
11.Mobility / A: Walk unaidedB: Walk with escortC: Walk with rehabaid
D: Wheelchair boundE: Bed ridden
12.Ability to climb
stairs/slope / A: Capable to climb stairs/slope by self
B: Climb stairs/slope with other’s assistance
C: Unable to climb stairs/slope even with other’s assistance
13.Public transport (Excluding taxi) / A: Manage without escortB: Manage with escort
C: Cannot manage with escort
14.Medication
15.Treatment required / A: Occupational therapyB: Physiotherapy
C: Others:
16.Rehabaid used / A: WheelchairB: AmbulatorC: Prosthesis/artificial legs
D: CalipersE: Special bootsF: Hearing aid
G: CrutchesH: TripodI: Others:

III.Location preference

Residential placement

Small group home for mildly mentally handicapped children (SGHMMHC)
Integrated Small group home for mildly mentally handicapped children (ISGHMMHC)
SGHMMHC + ISGHMMHC
No(Waiting time can be much shorter if applicant does not indicate location preference)
Yes(please indicate 5 choices in region/district/service unit)
Description
1.
2.
3.
4.
5.

IV.Declaration

Referrer has declared that there is no conflict of interest in handling this application. Referrer is not a family member or personal friend of the applicant and has no personal or social ties with the applicant.

Case ref. no.: / Tel.:
Name of referrer: / Fax.:
Office/Centre: / Date: