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 ______

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

1. Who is the legal guardian? ______

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

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

1. 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:______

______

______

1. Is the home handicapped accessible?______

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

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

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

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

1. How does the applicant handle transitions? ______

1. What are the applicant’s perceived strengths? ______

1. Please identify greatest areas of success/talents? ______

1. 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)

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

Family History: (check all that apply)

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

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