Please complete and submit the form below. Client Name* First Last Diagnoses Date of Birth* MM slash DD slash YYYY Gender*MaleFemale Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Legal Parent / Guardian* First Last Email* Phone* Split HomeYesNo(parents / guardians live in separate homes) Primarily Language / Cultural Considerations Services Information Support Coordinator Name First Last Support Coordinator Email Support Coordinator Direct Phone Service(s) Needed* Habilitation Respite Habilitation Hours Approved Weekly Respite Hours Approved Weekly Provider*I have a HAH/RSP Provider In MindI Need HOPE Group to Provide HAH/RSP Staff Client Basic Health Is client visually impaired?*YesNo If yes, details: Is client hearing impaired?*YesNo If yes, details: Is client physically impaired?*YesNo If yes, details: Allergies Medication / Supplement Name Dosage Frequency / Schedule Medication / Supplement Name Dosage Frequency / Schedule Medication / Supplement Name Dosage Frequency / Schedule Infection DiseaseYesNo Explain: (Details Here) Hospitalization, Operations, Other Medical ConditionsYesNo Explain: (Details Here) History of SeizuresYesNo Explain: (Details Here) Dietary Restrictions Dietary Considerations Food Selectivity Food Refusal G-Tube Requires Supplemental Nutrition (i.e. PediaSure) Adaptive Devices* Augmentative and Alternative Communication (AAC) Device Ankle Foot Orthodontics (AFOs)/Leg, Foot or Ankle Braces Glasses Hearing Aids Wheel Chair / Walker / Forearm Crutches Other Not Applicable If other, please describe: Communication How does your child currently communicate?* Assistive Communication Device Gesture PECS Sign Language Verbal: Fill out next section Other: Fill out next section Not Applicable If Verbal above, details here (estimate # of words) If Other above, details here Social and Play Skills How does your child currently interact with peers?AloneParallel PlayEngage with Others Safety Has the client worked on safety skills?*YesNoNot Applicable If yes, please explain: Gross and Fine Motor Are there any moving or lifting concerns that the provider needs to be aware of?*YesNoNot Applicable If yes, please explain: Daily Living Skills Dressing Undresses Dresses Puts on coat Puts on socks Puts on pants Buckles and unbuckles most buckles Zips and unzips front zippers Buttons and unbuttons front buttons Snaps and unsnaps front snaps Attempts to lace shoes Puts on shoes Attempts to tie shoes Hangs up own clothes on a hook Hangs up own clothes on a hanger Folds own clothes Puts clothes in drawer Bathing and Grooming Wipes nose with a tissue and puts it in the trash Uses a washcloth and soap when bathing Washes hair Brushes teeth Flosses teeth Washes hands Washes face Dries both face and hands Hangs up towel after washing Brushes hair Feeding Uses side of fork to cut softer foods Uses a knife for spreading Uses a knife for cutting Keeps eating area reasonably clean while eating Unwraps most food packaging Opens milk or juice container Pours liquids into a cup or bowl (from a small pitcher or lunch thermos) Helps to prepare simple foods (spreading, stirring, using cookie cutters, holding a beater, measuring ingredients, pouring ingredients) Helps to set the table for meals Takes dishes to the sink Wipes the table with a sponge or dish towel Toileting Aims into toilet standing (boys) Wipes self (girls wipe from front to back) Zips front zippers Buttons front buttons Snaps front snaps Washes and dries hands - as part of the toileting routine Night-time trained Behavioral Concerns* Stress/Anxiety Hair Pulling Biting Kicking Hitting Elopement/Running away Inappropriate Touch Self-Injury Pica Property Destruction Head Banging/Head Butting Verbal Aggression Pinching Scratching Food Selectivity/Refusal Inappropriate Sexualized Behavior Not Applicable Top 3 Areas of Concern* Gross/Fine Motor Independent Play Self-Help Skills Behavior Reduction Feeding Communication Social Skills Toileting Grooming Routine Dressing Other (fill out next section) If Other, details here: Availability for Habilitation Services Monday* 7:00 am 8:00 am 9:00 am 10:00 am 11:00 am 12:00pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm Not Applicable Tuesday* 7:00 am 8:00 am 9:00 am 10:00 am 11:00 am 12:00pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm Not Applicable Wednesday* 7:00 am 8:00 am 9:00 am 10:00 am 11:00 am 12:00pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm Not Applicable Thursday* 7:00 am 8:00 am 9:00 am 10:00 am 11:00 am 12:00pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm Not Applicable Friday* 7:00 am 8:00 am 9:00 am 10:00 am 11:00 am 12:00pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm Not Applicable Saturday* 7:00 am 8:00 am 9:00 am 10:00 am 11:00 am 12:00pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm Not Applicable Sunday* 7:00 am 8:00 am 9:00 am 10:00 am 11:00 am 12:00pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm Not Applicable Availability for Respite Services Monday* 7:00 am 8:00 am 9:00 am 10:00 am 11:00 am 12:00pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm Not Applicable Tuesday* 7:00 am 8:00 am 9:00 am 10:00 am 11:00 am 12:00pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm Not Applicable Wednesday* 7:00 am 8:00 am 9:00 am 10:00 am 11:00 am 12:00pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm Not Applicable Thursday* 7:00 am 8:00 am 9:00 am 10:00 am 11:00 am 12:00pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm Not Applicable Friday* 7:00 am 8:00 am 9:00 am 10:00 am 11:00 am 12:00pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm Not Applicable Saturday* 7:00 am 8:00 am 9:00 am 10:00 am 11:00 am 12:00pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm Not Applicable Sunday* 7:00 am 8:00 am 9:00 am 10:00 am 11:00 am 12:00pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm Not Applicable If services are needed past 7:00pm, please explain: Provider Preference*MaleFemaleNo Preference Is a provider needed who can help with dispensing medication?*YesNo Do you need a provider to transport the client?*YesNo If yes, please explain: CAPTCHA