Wheels on the Bus, Inc

Pre-Service Orientation Form

Provider’s Name: ______Provider’s Phone: ______

Employer Tax No.: ______AHCCS ID NO.: ______

Child’s Name: ______Assists #: ______DOB: ______

Child’s Address:______Phone #: ______

Responsible Party’s name: ______Relationship: ______

Support Coordinator name/location: ______Phone #: ______

Name of Day Program: ______Program Type: ______

Days and Hours of Attendance: ______Transportation Method: ______

Day Program Address: ______Phone #: ______

______------CURRENT MEDICATIONS AND MEDICAL ISSUES------______

Special Trianing Required?: ______Med Training Needed??______

Seizure Management Training??: ______Current Medications: ______

Med Log Required: □ Yes □ No Special Medication Instructions: ______

Allergies: □ Food ______□ Medications______

□ Other ______□ Bee Stings ______

Recommended response to allergic reaction: ______

Seizures: □ Yes □ No

Describe: ______Frequency: ______Approximate Duration: ______

Recommended response to seizure activity: ______

Assistive devices: □ Vision ______□ Hearing ______□ Dental ______

Protective Devices: □ Yes □ No

Instructions for Use: ______Purpose: ______

Other Individualized Health Care Routines: ______

Emergency Contact: Name ______Relationship ______

Phone (_____) ______-______Alt Phone (_____) ______-______

Name of ALTCS/DDD Health Plan: ______AHCCCS ID #: ______Phone #: ______

Other Health Insurance Information: ______

Primary Care Physician’s Name: ______Phone #: ______

Address: ______

Preferred Hospital or Urgent Care: ______Phone: ______

Child’s Name: ______Assists #: ______DOB: ______

Food:Independent with utensils □ Yes □ NoRequires limited assistance □ Yes □ No

Requires significant assistance □ Yes □ No Tube Feeding □ Yes □ No Eating disorder □ Yes □ No

Does food present a choking hazard? □ Yes □ No

Required consistency of food: □ Normal □ Chopped □ Pureed

Beverages:Independent with any cup/glass □ Yes □ NoIndependent with adaptive □ Yes □ No

Requires limited assistance □ Yes □ No Requires significant assistance □ Yes □ No

Independent in obtaining/requesting beverages □ Yes □ No

Describe adaptive eating/drinking equipment: ______

□ Uses complete sentences □ Uses simple sentences □ Signs □ Nods yes/no □ Gestures

Describe Augmentative Communication Devices (if applicable): ______

Balance while standing: □ Excellent □ Moderate □ Poor□ Utilizes Adaptive Aids

Method: □ Crawling □ Kneeling □ Standing □ Walking □ Running □ Climbing

Mobility Aids: □ N/A □ Walker □ Cane □ Crutches □ AFOs □ Leg braces □ Wheelchair

Positioning instructions: ______

Lifting/Carrying instructions: ______

Dressing: □ Independent □ Requires prompting □ Requires limited assistance