Preliminary Information
RAINBOW OMEGA, INC.
P.O. Box 740
Eastaboga, AL 36260-0740
(256) 831-0919
Preliminary Information
Type of Service Requested: ______Residential Care
______Respite
______Day Vocational Training
Date requested to be admitted for care: ______
(Please return to Rainbow Omega, Inc. at your earliest convenience.)
Section I: Applicant Data
Name of Applicant: ______
Address: ______
______
City State Zip
Phone: (____) ______
Date of Birth: ______Sex: M____F____
Name of Parents/Guardian: ______
Address: ______
______
City State Zip
Phone: (___) ______
______
Section II: Preliminary Assessment (Use additional pages as needed)
1. Please describe disability.
2. Please describe any health, social, or behavioral problems, which the applicant has experienced in the past five years.
3. How can Rainbow Omega be of help to you and the applicant?
Section III: Functional Limitation Areas
A. SELF CARE: Individual often needs the help of another person or a mechanical device, or takes a long time to take care of:
Personal hygiene - toileting, washing and bathing, tooth brushingYESNO
Grooming - dressing, undressing, hair and nail care, and overall appearanceYESNO
Feeding - eating/drinking, use of utensils, chewing, and swallowingYESNO
Needs to be prompted to take care of personal hygiene, grooming, or feeding YESNO
B. RECEPTIVE AND EXPRESSIVE LANGUAGE: Individual needs daily assistance from another person, or a person with special skills (such as sign language) or mechanical device to communicate (verbally or non-verbally).
Expressive: Has difficulty speaking intelligentlyYESNO
Has difficulty sharing information or communicating wants or needsYESNO
Receptive: Has difficulty hearing (without a hearing aid)YESNO
Has difficulty understanding an ordinary conversationYESNO
C. LEARNING: The individual needs special assistance to aid learning. The person may be unable, or very limited in their ability to acquire knowledge or to transfer knowledge or skills to new situations. The person may have difficulties with:
Cognition - recognition of persons, places, events, or objectsYESNO
Retention - short and/or long term memory YES NO
Reasoning - ability to grasp concepts, to perceive “cause and effect” relationshipsYESNO
ability to generalize information and skills from one situation to another
Academic skills - reading, writing, numerical concepts YESNO
D. MOBILITY: Individual needs the assistance of another person or a mechanical device or takes a long time, or requires a barrier-free environment, in moving from place to place in their homes or community. (This does not refer to the ability to operate motor vehicles or use public transportation.)
Individual needs or uses crutches, walker, or wheelchair for mobility YES NO
Walks independently, but takes a long time due to gait or coordination difficulties YES NO
Requires assistance in performing activities requiring manual dexterity, fine motorYES NO
control, or eye-hand coordination. (i.e. using an appliance)
E. SELF-DIRECTION: Individual needs help in making judgments and decisions concerning their personal or social life.
Emotional Development - has difficulties in coping with fears, anxieties, or YES NO
frustrations; emotionally unstable; exhibits low self-esteem
Interpersonal/Family Relations - has difficulties in establishing and maintaining YES NO
and maintaining relationships with family or peers; lacks social maturity and
awareness; is unable to protect self from exploitation
Initiative - has difficulties in making decisions regarding daily schedules or time YES NO
schedules or time management, unable to manage personal finances, or initiate
routine medical care
F. CAPACITY FOR INDEPENDENT LIVING: The individual is unable to live independently or to maintain normal societal roles, and may present a danger to him/herself with out the assistance or supervision of another.
Individual has difficulties performing simple household tasks such as bed making YES NO
& washing dishes
Has difficulties managing multiple step activities such as cooking, house cleaning, YES NO
and laundry
Has difficulty in traveling aloneYES NO
Has difficulty with using the telephoneYES NO
Has difficulty in understanding rules, restrictions, laws, or contractsYES NO
The individual has physical limitations that prevents him/her from living YES NO
independently unless support services are provided.
Section IV: Summary
This section is a summary of the definition of developmental disabilities. Rainbow Omega will apply this definition to determine, in part, the applicant’s need for the services offered by Rainbow Omega.
This applicant’s disability meets the following conditions:
1. Is attributable to a mental or physical impairment or combination of mentalYES NO
and physical impairments
2. Is (was) manifested before the age of 22YES NO
3. Is likely to continue indefinitelyYES NO
4. Results in substantial limitation in three or more of the following major life activities:
SELF CAREYESNO
RECEPTIVE/EXPRESSIVE LANGUAGEYESNO
LEARNINGYESNO
MOBILITYYESNO
SELF DIRECTIONYESNO
CAPACITY FOR INDEPENDENT LIVINGYESNO
ECONOMIC SELF-SUFFICIENCYYES NO
5. Reflects the person’s need for combination and sequence of special, YES NO interdisciplinary, or generic care. Reflects the person’s need for treatment
or other services that are lifelong or of extended duration and are individually
planned and coordinated.
Additional Comments:
______
I have completed the Preliminary Information packet and read the Rainbow Omega’s Admission Policy and Procedures, and I understand that every candidate for admission to Rainbow Omega must come for a pre-placement evaluation visit (minimum of 3 days/2 nights). Costs for respite may vary depending on individual needs and must be discussed with the CEO.
Person completing this document: ______Date: ______
Relationship to Applicant: ______
Address: ______
______
______
Phone: (____) ______
Form 301Page 1 of 4
Rev. 3/09