Intermediate Care Facility (Icf)

Carobell, Inc.

Empowering Individuals to

Reach Their Fullest Potential

INTERMEDIATE CARE FACILITY (ICF)

APPLICATION FOR ADMISSION

Carobell requires a severe or profound Intellectual Developmental Disability Diagnosis for admission.

North Carolina Medicaid is required. Carobell can assist with the Medicaid application process.

APPLICANT INFORMATION

Full Name:

Last First Middle (Nickname)

Residence:

Street Address City State Zip Code

Date of Birth: / Age: / Gender:
Social Security Number:
County, City, State of Birth:
County / City / State
County of Legal Residence:
Legal Guardian Name: / Type of Guardianship:
Provide the following information for the Legal Guardian:
Address:
Street Address City State Zip Code
Telephone:
Home / Work / Mobile
County: / E-Mail Address:

PARENT INFORMATION

Natural Mother’s Name:

First Middle Last Maiden

Current Address:

Street Address City State Zip Code

Telephone Number (including area code):
State of Residency: / Date of Birth: / Place of Birth:
mm / dd / yyyy
Natural Father’s Name:

First Middle Last

Current Address:

Street Address City State Zip Code

Telephone Number (including area code):
State of Residency: / Date of Birth: / Place of Birth:
mm / dd / yyyy

FINANCIAL RESOURCES INFORMATION

Public funds may be used only if and when other sources of first and third party payment have been exhausted. Carobell is responsible for establishing when a consumer has private insurance available, and we will assist the consumer in the coordination of private health care benefits. Carobell will also be responsible for billing private insurance when applicable.

Insurance Information

Please complete the following Insurance Information. Do not leave any area blank. If an area does not apply, please mark it N/A.

Medicaid #: / Medicare #:
Tricare:
Private Insurance Company Name:
Group #: / Subscriber #:

Entitlement Information

Please list monthly income from each applicable resource. If none, then mark N/A:

Innovations Services: / SSI: / SA:
Personal Funds: / Other:

APPLICANT’S MEDICAL INFORMATION

Primary Care Provider (Physician):
Address:
Telephone Number:

List all Applicant diagnoses:

Current medications:
Allergies:
Height: / Weight:
Etiology of Applicant’s Condition (events that led to applicant’s condition, if known):
Vision: / Normal / Impaired / Blind
Hearing: / Normal / Impaired / Deaf

BEHAVIOR INFORMATION

Does the Applicant have Behavioral Problems? If yes, please tell us how often (daily, weekly, monthly, etc) and how intensive (mild, moderate, severe):

Temper tantrums: / Yes / No / Frequency: / Intensity:
Screaming outbursts: / Yes / No / Frequency: / Intensity:
Head banging: / Yes / No / Frequency: / Intensity:
Breath holding: / Yes / No / Frequency: / Intensity:
Self-injurious behavior: / Yes / No / Frequency: / Intensity:
Aggressive toward others: / Yes / No / Frequency: / Intensity:
Any other behavioral issues (explain):
What is the best way to deal with these behaviors when they occur?
Does Applicant express fear? If yes please explain:

BIRTH HISTORY

Were there any complications with pregnancy, labor, or delivery (i.e.: prematurity, forceps delivery)? If yes, explain:

Was medical assistance needed after delivery? If yes, please explain:

Applicant’s Birth Weight: / Apgars Score:

FAMILY INFORMATION

Parents Marital Status:
List members of Applicant’s household:
Who is the primary caregiver for Applicant:
List others who assist with care:
Are both parents actively involved with Applicant’s care?

Has Applicant ever been placed outside of the home? If yes: where, when, and why?

CURRENT SELF CARE INFORMATION

Dining: / Bathing:
Independent / Independent
Minimal Assistance (Basic Reminders) / With Assistance (Verbal, Physical, Gestural)
Maximum Assistance (Physical/Verbal Assistance/Prompting) / Full Physical
Must Be Fed / Resists Bathing
Tube Fed
Problems with Dining: (Explain) / Problems with Bathing: (Explain)
Ambulation: / Dressing:
Ambulatory / Independent
Semi-Ambulatory (Explain Below) / Verbal Cues
Self Propels Wheelchair / Physical Prompts
Dependent Wheelchair / Must Be Dressed
Confined to Bed / Other Important Factors:
Other Info:
Toileting: / Communication:
Toilets Self / Verbal
Toilet Scheduled / Non-Verbal
Incontinent / Symbol Board
Displays potential for Training/Scheduling. / Manual Signs
Explain: / Gestures
None
Sleeping Habits:
Sleeps Through The Night
Gets Up to Go To The Bathroom
Sleeping During The Day
Bed Wetting
Problems Sleeping At Night (explain):
Receives Medication For Sleep (if so, what type/dosage)

Required items or concerns at night? (Bed rails, night lights, floor pads, etc.)

SOCIALIZATION

Does Applicant appear to be aware of his/her environment? If yes, explain:

What type of activities does the Applicant enjoy?

Why is placement currently being sought?

What special areas of concern do you have for him/her?

Which skills do you desire to see him/her improve?

Please list any other pertinent information Carobell should know about Applicant:

Signature of Parent/Guardian / Date
Signature of Parent/Guardian / Date
Printed Name of contact person:
Date: / Contact Number:

The following items must be submitted with the application:

Psychological evaluation (current within 3 years) stating level of Intellectual Developmental Disability

Current photograph

The following items are also helpful in our admissions process:

Physical therapy evaluation

Occupational therapy evaluation

Speech/language evaluations

Dental evaluation

Audiological evaluations

Vision evaluations

Parent/guardian must apply for Medicaid prior to admission to Carobell, Inc.

The following items will be requested if applicant is approved for placement on our waiting list:

Medical history

Immunization records

Birth Certificate

All insurance information

ICF / IDD Facilities in North Carolina
Facility Name / Location of Facility / Contact number
Carobell, Inc / Hubert, NC / 910*326*7600
Community Innovations / Elizabethtown, NC / 910*826*8363
Community Innovations / Laurinburg, NC / 910*277*3212
Community Innovations / Lumberton, NC / 910*739*8849
Community Innovations / New Bern, NC / 252*638*1028
ComServ / Morganton, NC / 828*325*4926
Gaston Residential / Gastonia, NC / 704*861*9280
Holy Angels / Belmont, NC / 704*825*4161
Howell’s Support Services / Goldsboro, NC / 888*828*3096
Irene Wortham Residential / Ashville, NC / 828*274*7518
Macon Citizens for Handicapped / Franklin, Nc / 828*524*5888
Mountain Area Residential / Ashville, NC / 828*299*3636
Piedmont Residential / Concord, NC / 704*788*2304
Pitt County Group Homes / Greenville, NC / 252*524*4950
RHA / Ashville, NC / 828*232*6488
Rouse Group Homes, Inc / Madison, NC / 336*427*0609
Skill Creations / Goldsboro, NC / 919*734*7398
Tammy Lynn Center / Raleigh, NC / 919*832*3909
Wilson-Gilmore Services / Hope Mills, NC / 910*484*3717
WNC Autistic Group Homes / Ashville, NC / 828*274*8368

ICF Application Page 1 of 6 Rev: 11/05, 6/12, 10/14, 2/16, 8/17