This Is an Application for Admission to This Hospital for Medical Rehabilitative Services

APPLICATION FOR ADMISSION

This is an application for admission to this hospital for Medical Rehabilitative Services

Please return completed application to:

Pappas Rehabilitation Hospital for Children

3 Randolph Street

Canton, MA 02021

ATTN: Admissions Department

DEMOGRAPHIC INFORMATION

(PLEASE PRINT)

Applicant’s Full Name:(Last) ______(First) ______(MI)______

Sex: M □ F □ Date of Birth: ______Age______

Birthplace: ______Social Security No. ______- ______- ______

Current Residence: ______

(No. & Street Name) (City/Town)(State) (Zip Code)

Current Home Telephone Number: ( ) ______- ______

Father’s Name:______Age:______

Address: ______

(No. & Street Name) (City/Town)(State) (Zip Code)

Telephone Numbers: Home: ( ) ______- ______Cell: ( ) ______- ______

Email Address: ______

Employer: ______

Address: ______

Work Telephone Number: ( ) ______- ______

Mother’s Name: ______Age:______

Address: ______

(No. & Street Name) (City/Town)(State) (Zip Code)

Telephone Numbers: Home: ( ) ______- ______Cell: ( ) ______- ______

EmailAddress: ______

Employer: ______

Address:______

Work Telephone Number: ( ) ______- ______

Are parents married: □ Yes □ No If no, how long divorced, separated, living together? ______

______

CASE MANAGEMENT/PSYCHOSOCIAL

Agency Involvement

Agency Agency Contact Person and Telephone Number

□ DDS ______

□ DCF ______

□ MRC ______

□ MCB ______

□ SHIP ______

□ DPH ______

□ VNA ______

□ PCA’s______No. of hours: ______

□ Other ______

With whom does applicant reside (names/ages/relationship)? ______

Who is the legal guardian? ______

Any siblings or parents that do not reside in home?______

Visitation schedule if parents are divorced/not living together?______

Are any legal problems being presently addressed by family? Yes □ No □

If yes, please describe: ______

______

Any custody, visitation and/or restraining orders? Yes □ No □

If yes, please describe:______

______

Is the home handicapped accessible?______

Do you have transportation that meets the need of the applicant?______

Does the applicant use PCA services in the home? Yes □ No □

If yes, how many hours a week does applicant use PCA services? ______

Is applicant able to direct care of PCA’s? ______

How does the applicant handle transitions? ______

What are the applicant’s perceived strengths? ______

Please identify greatest areas of success/talents? ______

Is the applicant aware of the application to PRHC? ______

How does the applicant feel about possibly residing at PRHC?______

______

PRHC may require a home visit if Admission Team finds necessary.

Families may request a home visit as part of the pre-admission process.

SCHOOL INFORMATION

Applicant’s CurrentSchool: ______

Address: ______

(No. & Street Name) (City/Town)(State) (Zip Code)

Telephone Number: ( ) ______- ______

School Contact: (Name) ______Telephone Number: ( ) ______

Does your child have a current/signed IEP? Yes □ No □

If not, please explain:______

Is your local school system aware of application to PRHC? Yes □ No □

If yes, do they support the application? Yes □ No □

INSURANCE INFORMATION

Prior to admission, applicant must be enrolled in Mass. Health. If not currently enrolled, please contact

Mass Health to start application process.

Applicant’s Medical Insurance Company: ______

(Name of Insurer/Company)

Subscriber’s Name: ______

Address if different from Applicant’s: ______

(No. & Street Name) (City/Town) (State) (Zip Code)

Policy No. ______

I.D No.______

(Private Insurance:ex: BCBS if applicable) ______

Medicare No. (if applicable): ______

Medicaid No. (if applicable): ______

(Mass Health No.) (Medicaid Claim No.)

Has applicant been the recipient of a Monetary Award of Settlement? Yes □ No □

What type of Mass Health? Comm. Health□ TAFDC□ SSI□ SSI/SSDI□ Other□

Is patient on: SSI? Yes □ No□ Monthly Amount: $______

SSDI? Yes □ No□ Monthly Amount: $______

SSI/SSDI? Yes □ No□ Monthly Amount: $______

Does patient receive child support? Yes □ No□ Monthly Amount: $______

Does patient have a Trust Fund?Yes □ No□ Monthly Amount: $______

If yes, is Trust Fund a special needs/irrevocable Trust Fund? Yes □ No □

Is Trust Fund in patient’s name? Yes □ No □

If no, whose name is it in? ______

Lawyer’s Name & Address: ______

Does patient have a savings account? Yes □ No□ Amount: $______

Does patient have a checking account? Yes □ No□ Amount: $______

Would you be setting up a personal needs account at PRHC? Yes □ No □

Would you be agreeable to Direct Deposit of SSI/Long Term Care Check? Yes □ No □

GENERAL QUESTIONS

Have you ever applied to PRHCbefore? Yes □ No □ If yes, When? ______

What are your reasons for applying to PRHC?

______

Are you currently applying to any other facility, if so where? ______

Name of person filling out application:______

Address:______

(Street No.) (City/Town)(State) (Zip Code)

Telephone Number: ( ) _____-______

If PRHC staff recommends your child for inclusion in the therapeutic leave program, will you be supportive of his/her participation? Yes □ No □

PSYCHOLOGY

Family History: (Please include immediate family in and outside the home and all individuals living

in the home)

□Substance Abuse

□Domestic Violence

□Psychiatric Illness

Describe in detail any of the above that are checked:

______

Describe past/present experiences in school: (Including issues re: accessibility, peer interactions, ability to function in the school setting)

______

Availability of extracurricular recreational and social resources/activities at school setting:

______

Is/was your child bullied or harassed at school? Yes □ No □ if yes, please describe:

______

Is/was your child socially isolated at school? Yes □ No □ if yes, please describe:
______

______

Does your child have any friends outside of school?

______

How does your child get along with peers/other children?

______

Please describe other alternatives you have tried if regular school attendance has not been successful

(ex: home tutoring)

______

Is your child able to get into the community on a regular basis? (doctor’s appointments, family events)

______

Describe any psychology concerns/stressors:

______

Has your child/family received mental health therapy? Yes □ No □ If yes, where and for how long?

______

What is your child’s mood most days: ______

______

Does your child have behavior problems which interfere with daily tasks, for example need for a behavior support plan, 1-1 supervision: ______

______

THERAPIES

Mobility/Transfers:

How do you transfer your child? ______

Does your child use a wheelchair? ______

 Manual Wheelchair

 Power Wheelchair

Does your child walk? If yes, please describe equipment used: ______

______

Does your child require a special bed, side rails or side pads? If yes, please describe equipment used: ______

Safety (check all that apply):

Falls frequently
Wanders
Climbs out of bed

Communication

Expressive Communication Modes: check all used by individual to make needs known

□ Speech□ Signs, gestures, vocalizations

□ Writing/typing□ AAC System:

□ Consistent reliable yes/no□ other: ______

______

Making self-understood/Partner Response:

□ understood□ usually understood□ difficulty finding words/finishing thoughts

□ sometimes understood □ limited to simple direct communication □ rarely/neverunderstood

Receptive Communication:

Other related issues: ______

______

Other receptive communication techniques used: (ex: lip read, visual supports)

______

Comprehension/ability to understand others:

□ understands□ usually understands may miss some part/intent of message

□ sometimes understands, responds adequately to simple, direct communication

□ rarely/never understands□ to be determined

Oral Motor/Swallowing

Is he/she on a modified texture diet? Solids: Yes □ No□ Liquids: Yes □ No □

If yes, explain: ______

______

Has the patient ever had a Modified Barium Swallow? (swallowing study) If yes, when, where, results/recommendations:______

______

*Please attach copy of most recent swallowing study evaluation*

NUTRITION

Height: ______Weight: ______

Has the patient recently lost or gained any weight? Yes □ No □

Amount of weight lost: ______

Amount of weight gained: ______

Over how long? ______

Was it intentional? ______

DENTAL INFORMATION

Name of Dentist: ______

Address: ______

(No. & Street Name) (City/Town)(State) (Zip Code)

Telephone Number: ______

Medical History Information

Diagnosis: (Please list all diagnoses, infections or medical problems that your child has or has had)

______

Surgical History:(Please list all surgeries your child has had)

Surgery Physician/Hospital Date

______

Planned Surgeries: (Please list any planned/upcoming surgeries or doctor appointments)

Surgery/Appointment Physician/Hospital Date

______

Allergies or Reactions to:______

Medications: ______

Iodine, dyes, anesthetics: ______

Food: ______

Environmental ex: dust/cats:______

Latex: Yes □ No □______

Medical Problems/Issues/Concerns: (Check all that apply)

Seizures / Pneumonia / Constipation
Loss of consciousness/Severe head trauma / Aspiration / Diarrhea
Attention Deficit Disorder / Special diet / Lactose intolerance
Developmental disorder / Legally Blind / Heart palpitations
Spasticity or high tone / Recent weight loss or weight gain / Other heart problems
Decreased tone / Leg swelling / High blood pressure
Easy bruising / Ostomy bag / Low blood pressure
Bone fractures / Hepatitis / Chest pain or discomfort
Fragile bones / Diabetes / Shunt
Vagal Nerve Stimulator / Bladder problems / Autonomic dysreflexia
discomfortBreathing problems / Bladder infections / Headaches/Migraines
Uses a ventilator or CPAP / Kidney infections / Vision problems
Uses oxygen / Kidney stones / Wears glasses
Asthma / Blood in urine / Hearing problems
Difficulty swallowing food/saliva / Blood in stool / Wears hearing aid
Frequent choking / C difficile (diarrhea) / Nebulizer/Inhaler/IPV
Liver problems / Obesity / SBE prophylaxis
Digestive problems / Poor weight gain / Skin issues, pressure sores
Gastro –esophageal reflux / Problems with overeating / Eczema/Dermatitis
Gastric or duodenal ulcer / Problems with under eating / Menstrual problems
Recent exposure to tuberculosis (+TB test) / G-tube Feeding / Uses catheters
Pain ___Acute _____Chronic / Needs suctioning / Other (please specify below

If you have checked any of the above, please explain:

______

Yes No Not Sure

Does your child sleep through the night? ______

Has he/she ever had a hearing test?______

Does your child need diapers?______

Does your child use the toilet?______

Has your child ever had a behavioral plan?______

Other Observations/Comments or things you think are important to know about your child:

______

Birth History

Mother’s age at Delivery:
General state of health during pregnancy (circle one) : Poor Fair Good Excellent
Problems during pregnancy:
Birth Weight: (circle one): Pre-term Term
Problems at birth of shortly after:
Developmental Delays:

Family History: (check all that apply)

Diabetes / Seizures / Kidney/bladder problems
Heart disease / Neurological problems / GI problems
High cholesterol / Psychiatric problems / Immunological problems
Cancer / ADHD/ADD / Sudden death
Other:

Doctors:(including Mental Health providers, i.e.: psychiatry, therapist, social worker, counselor)

Name / Specialty/Medical Problem / Location

Immunizations

*Please include a copy of all immunizations (vaccines) *

Please list all Medications including vitamins, supplements, over the counter medicines and skin care:

Name Dosage Number of Times Daily

PLEASE NOTE IF ANY MEDICATIONS MUST BE RECONSTITUTEDPRIOR TO ADMINISTRATION.(Reconstitution is the process of adding diluents to a dry ingredient to make it a liquid)

Revised: 7/17 Page 1 of 11 FORM#: AD-001

Department: Admissions