New Member Intake Form New Member Intake FormPlease enable JavaScript in your browser to complete this form. - Step 1 of 5Guardian/Responsible Party's InformationName *FirstLastPhone *Relationship to Member *ParentGrandparentOther RelativeOther Legal GuardianEmail *Have you ever had an Auto Visit Account for timecard approval? *YesNoIf yes, what email did you use for your login?Member InformationName *FirstLastBirthdate *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSupport Coordinator Name *FirstLastEmergency ContactName *FirstLastRelationship to Member *Phone *NextHealth-MedicalCurrent Medications and Significant Historical Issues:Med Log Required *YesNoSpecial Medication Instructions:Allergies To:Food *YesNoSpecifyMedication *YesNoSpecifyBee Stings *YesNoSpecifyOther *YesNoRecommended Response to Allergic Reaction:SeizuresSeizures *YesNoFrequencyApproximate DurationRecommended Response to Seizure Activity:Assistive DevicesProtective/Assistive Devices: *VisionHearingDental AppliancesOtherNonePurpose/Instructions for UseOther Individualized Health Care RoutinesDescribe:NextPre-Service Provider OrientationDietFood:Independent with Utensils *YesNoIndependent with Specific Utensils *YesNoRequires Limited Assistance *YesNoRequires Significant Assistance *YesNoDoes Food Present A Choking Hazard? *YesNoRequired Food Constistency *NormalChoppedPureedSpecial DietTube Feeding (if yes, include instructions) *YesNoEating Disorder (if yes, describe) *YesNoInstructions/Description:Beverages:Independent with Any Cup/Glass *YesNoIndependent with Adaptive *YesNoRequires Limited Assistance *YesNoRequires Significant Assistance *YesNoIndependent in Obtaining/Requesting Beverages *YesNoDescribe adaptive eating/drinking equipmentDescribe if Special Liquid Intake NeedsSpecial for Fluid Intake (if applicable)CommunicationCommunication Skills: (check all that apply) *Uses Complex SentencesUses Simple SentencesSignsNods Yes/NoGesturesDescribe Augmentative Communication Devices (if applicable)MobilityBalance While Standing: *Excellent (not an issue)Moderate (e.g., stumbles)Poor (e.g., very unsteady, falls)Utilizes Adaptive Aids for Balance *YesNoIndependent Mobility (Check as Applicable) *Crawling/ScootingKneelingStandingWalkingRunningClimbingMobility Balance Aids (Check as Applicable) *N/AWalkerCaneCrutchesAFOsLeg BracesWheel ChairRunning ClimbingOther (specify)Positioning InstructionsLifting/Carrying InstructionsNextPersonal Care Skills (Check All Applicable Items)DressingIndependentRequires Prompting/RemindingRequires Limited Assistance/SupervisionRequires Significant AssistanceToiletingIndependentRequires Prompting/RemindingRequires Limited Assistance/SupervisionRequires Significant AssistanceBathingIndependentRequires Prompting/RemindingRequires Limited Assistance/SupervisionRequires Significant AssistanceDental CareIndependentRequires Prompting/RemindingRequires Limited Assistance/SupervisionRequires Significant AssistanceMensesIndependentRequires Prompting/RemindingRequires Limited Assistance/SupervisionRequires Significant AssistanceMed. AdminIndependentRequires Prompting/RemindingRequires Limited Assistance/SupervisionRequires Significant AssistanceOtherIndependentRequires Prompting/RemindingRequires Limited Assistance/SupervisionRequires Significant AssistanceDescribe Special Personal Care Needs and Preferences:Behavioral Concerns (If Applicable)CIT TrainingYesNoDescription of Behavioral Concern (Check All that Apply):AggressionSelf-Injurious BehaviorProperty DestructionAWOLSelf-StimulationSexual Acting OutOtherDescribe Frequency and Recommended Intervention:Is a Behavioral Treatment Plan (BTP) Available for Additional Information?YesNoReason for BTP:Method Used to Obtain Information (e.g., in person, case file):NextSignatureGuardian/Responsible Party Name *FirstLastDate / Time *SignatureClear SignaturePhoneSubmit