New Member Intake Form – All Aboard Services

Guardian/Responsible Party's Information

Name *

First

Last

Phone *

Relationship to Member *

Email *

Have you ever had an Auto Visit Account for timecard approval? *

Yes
No

If yes, what email did you use for your login?

Member Information

Name *

First

Last

Birthdate *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Support Coordinator Name *

First

Last

Emergency Contact

Name *

First

Last

Relationship to Member *

Phone *

Health-Medical

Current Medications and Significant Historical Issues:

Med Log Required *

Yes
No

Special Medication Instructions:

Allergies To:

Food *

Yes
No

Specify

Medication *

Yes
No

Specify

Bee Stings *

Yes
No

Specify

Other *

Yes
No

Recommended Response to Allergic Reaction:

Seizures

Seizures *

Yes
No

Frequency

Approximate Duration

Recommended Response to Seizure Activity:

Assistive Devices

Purpose/Instructions for Use

Other Individualized Health Care Routines

Describe:

Pre-Service Provider Orientation

Diet

Food:

Independent with Utensils *

Yes
No

Independent with Specific Utensils *

Yes
No

Requires Limited Assistance *

Yes
No

Requires Significant Assistance *

Yes
No

Does Food Present A Choking Hazard? *

Yes
No

Required Food Constistency *

Normal
Chopped
Pureed

Special Diet

Tube Feeding (if yes, include instructions) *

Yes
No

Eating Disorder (if yes, describe) *

Yes
No

Instructions/Description:

Beverages:

Independent with Any Cup/Glass *

Yes
No

Independent 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

Describe if Special Liquid Intake Needs

Special for Fluid Intake (if applicable)

Communication

Describe Augmentative Communication Devices (if applicable)

Mobility

Balance While Standing: *

Excellent (not an issue)
Moderate (e.g., stumbles)
Poor (e.g., very unsteady, falls)

Utilizes Adaptive Aids for Balance *

Yes
No

Positioning Instructions

Lifting/Carrying Instructions

Personal Care Skills (Check All Applicable Items)

Dressing

Independent
Requires Prompting/Reminding
Requires Limited Assistance/Supervision
Requires Significant Assistance

Toileting

Independent
Requires Prompting/Reminding
Requires Limited Assistance/Supervision
Requires Significant Assistance

Bathing

Independent
Requires Prompting/Reminding
Requires Limited Assistance/Supervision
Requires Significant Assistance

Dental Care

Independent
Requires Prompting/Reminding
Requires Limited Assistance/Supervision
Requires Significant Assistance

Menses

Independent
Requires Prompting/Reminding
Requires Limited Assistance/Supervision
Requires Significant Assistance

Med. Admin

Independent
Requires Prompting/Reminding
Requires Limited Assistance/Supervision
Requires Significant Assistance

Other

Independent
Requires Prompting/Reminding
Requires Limited Assistance/Supervision
Requires Significant Assistance

Describe Special Personal Care Needs and Preferences:

Behavioral Concerns (If Applicable)

CIT Training

Yes
No

Describe Frequency and Recommended Intervention:

Is a Behavioral Treatment Plan (BTP) Available for Additional Information?

Yes
No

Reason for BTP:

Method Used to Obtain Information (e.g., in person, case file):

Signature

Guardian/Responsible Party Name *

First

Last

Date / Time *

Signature