Hartwood Foundation, Inc

HARTWOOD FOUNDATION, INC.

3702 Pender Drive * Suite 410 * Fairfax, VA 22030

703-273-0939 (phone) * 703-273-6807 (fax)

We’re opening a lot of doors.

HFI Processing Information (this section to be filled out by HFI staff):

DATE INITIALS

Referral Letter Received ______

Application Received ______

Follow-Up Contact ______

Intake Meeting ______

Intake Decision ______

Date of Admission ______

APPLICATION FOR SERVICES

* Family/ Caregivers/ Support Coordinators: Complete the following information regarding the individual applying for services and return to the address above.

A. Hartwood Service(s) Applying for:

□ Hartwood Operated Group Home (24-hour, around-the-clock staff support available)

□Hartwood Operated Supervised Living (SLR) Residence(Generally 8.0 hours staff support daily)

□ In-Home Supports(Hartwood employs staff to provide services in individual’s home; for individuals with CL, FIS

waiver – must be referred / approved by CSB)

□ Drop-In Supports (Hartwood employs staff to provide services in individual’s home; for individuals without a

waiver – must be referred / approved by CSB)

□ Emergency Respite (Emergencyadmission/stays at Hartwood Respite Facility – must be referred / approved by CSB)

□Private (county- subsidized) or Waiver-Funded Respite (for individuals with CL, FIS waiver)

(Planned stays at Hartwood Respite Facility)

□ Respite Subsidy (County-funded partial reimbursement to families who hire own caregiver; for Non-waivered Individuals)

B. General Information of Service Applicant

1. Applicant’s Name ______

2. Present Address ______

______

3. Permanent Address______

______

4. Home Telephone ______5. Day Telephone ______

6. Date of Birth ______7. Place of Birth ______

8. Gender: □ Male □ Female9. Social Security Number ______

10. Citizenship Status______11. Marital Status ______

12. Is Individual own Legal Guardian? □ Yes □ No

If no, please list guardian info: ______

13. Language spoken and/or understood ______

14. Religious Preference* ______

* Provision of this information is voluntary. HFI does not discriminate against applicants because of race,

sex,creed, religious or national origin.

15. Medical Insurance (company/policy number) or Medical Assistance

(type/number) (type/number) ______

16. Does individual have a Waiver? □ Yes □ No

If Yes, please specify type: ______

C. Identification Information

1. Height _ _ 2. Weight 3. Eye Color ______

4. Hair Color ______5. Identifying Marks ______

6. Recent Photograph (please attach)

D. Family Information

1. Next-of-kin (if parents are deceased)

a. Name ______

b. Address______

______

c. Telephone Number ______

d. Nature of Relationship ______

2. Sibling(s) Information:

Name Age Sex Address

E. Emergency/Other Contacts

1. Physician / Primary Doctor

a. Name ______

b. Address ______

______

c. Telephone Number ______

2. Psychiatrist / Therapist

a. Name ______

b. Address ______

______

c. Telephone Number ______

3. Pastor/Priest/Rabbi *______

* Provision of this information is voluntary. HFI does not discriminate against applicants because of race,

sexcreed, religious or national origin.

Telephone number ______

4. CSB Support Coordinator(if assigned)______

Telephone number______

F. Program Information

Employment / Day Support Background (List current or most recent as applicable)

a. Employer ______

b. Address ______

______

c. Telephone Number ______

d. Supervisor / Job Coach ______

e. Dates of Employment ______

Educational Background

a. School ______

b. Address______

______

c. Telephone Number ______

d. Diploma / Highest grade completed ______

e. Dates of Attendance ______

Vocational/Other Training Background (List present or most recent training program. Attach separate

page for additional trainings.)

a. Name ______

b. Address ______

______

c. Telephone Number ______

d. Supervisor / Counselor ______

e. Areas of Training ______

f. Dates of Attendance ______

4. Residential Program Background (If applicable; list additional information on separate page.)

a. Program / Agency Name ______

b. Address ______

______

c. Telephone Number ______

d. Manager ______

e. Dates resided there ______

G. Applicant Support Information

1. Medical, Behavioral and Social condition(s) resulting in need for support;

Name(s)/Diagnoses ______

______

b. Nature of diagnose(s)

1) General Capabilities:

2) Major Limitations / Restrictions to daily activities:

3) Use of adaptive devices /equipment (wheelchair, walker, etc.):

2. Medical Status/History

a. Description of general health:

b. Last Physical (physician/date) ______

c. Current Medications (prescription and nonprescription, type,dosage, frequency, condition

beingtreated, method of administration; please note "None" if appropriate):

d. Allergies (note "None" if appropriate):

e. List any drug allergies, idiosyncratic or adverse drug reactions:

f. List any past ineffective medication therapy:

g. Any recent physical complaints:

h. Past serious illnesses, infectious diseases, serious injuries and hospitalizations:

i. Substance abuse history, if applicable:

3. Sexual Health and Reproductive History

a. List and describe any past/present sexual health issues:

b. Does the applicant have any children? □ Yes □ No

If yes, list name(s), age(s), address(es), frequency of contact, and if any issues:

4. Independent/Personal Living Skills

a. Self-help (grooming, dressing, bathing, feeding, toileting support needs):

b. Communication (strengths and support needs):

c. Household (cleaning, cooking, laundry):

d. Leisure (interests, activities, hobbies):

e. Mobility (if cane, walker, or wheelchair used, please note):

f. Behavioral (list strengths and support needs):

g. Community Activities (shopping, banking, use of public transportation):

H. Financial Information

1. Representative Payee for Benefits: ______

2. Income/Assets

a. Salary/ Wages $ per ______

b. Savings (amount) $______

d. Other assets (please specify nature and value) $______

3. Government Benefits / Financial assistance received (fill in monthly amount if applicable)

a. SSA ______d. SSI ______

b. RSDI ______e. Food Stamps ______

c. Medicaid ______f. Other (please specify) ______

I. Personal Information

Why does applicant want/need to receive services? (Specify exact needs.)

How soon are services needed? (If immediately, please specify a reason and give dates.)

3. When, where, and how (and who) would you like us to contact?

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* Following Questions for Respite Subsidy Program Applicants Only:

1. Preferred location of respite services: □family home □ provider home □either

2. General days and times/time frames that services are needed:

3. Would you like a copy of Hartwood’s “Interested Provider” list? □ Yes □ No

(If yes, release form must be completed prior to provision of list)

4. Would provider(s) be responsible for administering medications? □ Yes □ No

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______

Signature of Applicant Date

______

Signature of Parent/ Guardian/ Authorized RepresentativeDate

______

Signature & title/ relationship of person completing application Date

(if different from above)

Form 9-01, Rev. 5/18