To apply for RESIDENTIAL or COMMUNITY DAY SERVICES at Marklund, please fill out form below.

 

Birthdate:

Gender:

County:

Birthplace (City/State/Country):

US Citizen:

Religion:

Race:

Primary Language Spoken/Understood:

Highest Level of Education:

School Name:

Attends Day Program:

Program Name:

Public Aid Case #:

Public Aid Recipient ID#:

Social Security Number:

Medicare Number:

If private insurance, name of company:

Policy Holder Name:

Policy Number:

Group Number:

Home Based Support from DHS:

Father Name:

Father Street Address:

Father City:

Father State:

Father Zip Code:

Father Telephone:

Father DOB:

Father Birthplace (City/State/Country):

Father Cell Phone:

Father e-mail:

Father Occupation:

Father Employer Address:

Father Work #:

Father S.S.#:

Father Highest Level Of Education:

Parent Marital Status:

Mother Name:

Mother Street Address:

Mother City:

Mother State:

Mother Zip Code:

Mother Telephone:

Mother DOB:

Mother Birthplace (City/State/Country):

Mother Maiden Name:

Mother Cell Phone:

Mother e-mail:

Mother Occupation:

Mother Employer Address:

Mother Work #:

Mother S.S.#:

Mother Highest Level Of Education:

Court Appointed Guardian:

Other Name:

Other Street Address:

Other City:

Other State:

Other Zip Code:

Other County:

Other Township:

Other Home Telephone:

Other Work #:

With whom does the Client live:

If other, Name and Address:

Relation:

Sibling 1:

Sibling 1 Sex:

Sibling 1 Birthdate:

Sibling 1 Live with Parent:

Sibling 2:

Sibling 2 Sex:

Sibling 2 Birthdate:

Sibling 2 Live with Parent:

Sibling 3:

Sibling 3 Sex:

Sibling 3 Birthdate:

Sibling 3 Live with Parent:

Siblings Deceased, Name, Age At Death:

Guardian Household Size:

Guardian Annual Household Income:

Primary Diagnosis:

Age at Onset:

Diagnosis Caused By:

Other Medical Conditions:

Level of Disability:

Epilepsy/Seizure Disorder:

How often, if yes:

If Epilepsy/Seizure Disorder:

Describe Epilepsy/Seizure:

Immunizations up to date:

Medications name, dosage & times:

Hospitalization 1 Hospital:

Hospitalization 1 Reason:

Hospitalization 1 Length of Stay:

Hospitalization 2 Hospital:

Hospitalization 2 Reason:

Hospitalization 2 Length of Stay:

Allergies:

If yes, to what and what is the reaction:

Intolerances:

If yes, to what and what is the reaction:

Apnea Monitor:

Cardiac Monitor:

Nebulizer:

Trach:

Moisture:

Oxygen:

Liter Flow:

Suctioning:

Communicable Disease 1:

Communicable Disease 1 Year:

Communicable Disease 2:

Communicable Disease 2 Year:

Client’s Weight:

Client’s Height:

Diet Consistency:

Liquid Intake Method:

Type of Gastrostomy Tube:

Type of Formula:

How often is G-tube changed:

Does Client have episodes of vomiting:

How Often:

Eating Habits:

Eating Intolerances:

Cognitive Level of Functioning:

Developmental List:

Describe protective device on bed:

Wheelchair:

Wheelchair stabilizers:

Are there any contractures:

If contactures, where:

Muscle Tone:

Have there been any orthopedic surgeries:

Surgery 1 Date:

Surgery 1 Outcome:

Surgery 2 Date:

Surgery 2 Outcome:

Surgery 3 Date:

Surgery 3 Outcome:

Awareness of:

Responds to:

Localizes to:

Communication Device:

No behavior problems:

Potential behavior problems:

Other Potential Behavior Problems:

Are the methods successful:

Likes:

Dislikes:

Sleeping Habits:

Birth History:

Developmental History:

Employment/Developmental Training Hist.:

Need for Marklund services:

Person Completing Form:

Relation to Client:

Signature Date: