Client Admission Packet

Sex? Male Female

Social History

Placement History

Residential Placements School / Day Program / Vocational Placements

Medical History

Current Medications Allergies (Please list allergies and type of reaction to)

Functional Skills Checklist

Eating?
Independent
Minimal Supervision Needed
Substantial Supervision Needed
Total Care Needed Dressing?
Independent
Minimal Supervision Needed
Substantial Supervision Needed
Total Care Needed
Grooming?
Independent
Minimal Supervision Needed
Substantial Supervision Needed
Total Care Needed Toileting?
Independent
Minimal Supervision Needed
Substantial Supervision Needed
Total Care Needed Mobility within Facility?
Independent
Minimal Supervision Needed
Substantial Supervision Needed
Total Care Needed Mobility within Community?
Independent
Minimal Supervision Needed
Substantial Supervision Needed
Total Care Needed Describe Applicant's Communication Abilities

Behavioral Checklist

Please select the button that most closely describes the frequency of the behaviors listed for this applicant Withdrawal
Daily to several times a week
Weekly
Several Times a month
Monthly
Less than a month
None Injurious to self
Daily to several times a week
Weekly
Several Times a month
Monthly
Less than a month
None Physically Aggressive to Others
Daily to several times a week
Weekly
Several Times a month
Monthly
Less than a month
None Verbally Aggressive to Others
Daily to several times a week
Weekly
Several Times a month
Monthly
Less than a month
None Property Destruction
Daily to several times a week
Weekly
Several Times a month
Monthly
Less than a month
None Disruption of Other's Activities
Daily to several times a week
Weekly
Several Times a month
Monthly
Less than a month
None Noncompliance/Rebelliousness
Daily to several times a week
Weekly
Several Times a month
Monthly
Less than a month
None Inappropriate Sexual Behavior
Daily to several times a week
Weekly
Several Times a month
Monthly
Less than a month
None Stereotypic Behaviors (Rocking, etc.)
Daily to several times a week
Weekly
Several Times a month
Monthly
Less than a month
None

STEP, Inc. Individual Abuse Prevention Plan Admission Assessment

Please review and identify areas in which this individual may be susceptible to abuse or at risk of abusing other vulnerable people. STEP will use this information to develop a plan that gives specific measures that staff will take to protect the individual and minimize the risk in identified areas. Physical Abuse
Has history of being physically abused or assaulted
Inability to identify potentially dangerous situations
Inappropriate interactions with others
Inability to deal with verbally/physically aggressive persons
Verbally/physically abusive to others
Other Sexual Abuse
Is unable to exercise judgement and give consent to sexual activity
Has history of being sexually abused or exploited
Is unable to protect self from sexual exploitation or sexual assault
Likely to seek or cooperate in an abusive situation
Verbally/physically abusive to others
Other Financial Exploitation
Is not capable of handling personal funds or understanding value of money
Gives away money or allows money or other property to be taken away
Does not carry or store money or valuables safely Self-abuse
Has history of self-injurious behavior
Dresses neglectfully
Refuses to eat
Lacks hygiene skills (handwashing, toileting, bathing, etc.)
Lack of self-preservation skills (ignores personal safety)
Neglects or refuses to take medications
Other History of violent crime or acts of physical aggression toward others
History of violent crime indicated by law enforcement or medical records
History of physical aggression toward others

Emergency Information

In the event of an emergency, contact: If the above person cannot be reached in an emergency, contact: The following are the medical and dental providers and hospital preference for this person: I understand that the medical provider, family, caregiver and/or residential provider and/or caregiver will be notified as soon as possible. In case of not being able to reach the medical provider or hospital of preference, I authorize STEP, Inc. to secure medical assistance at the best possible location.

Release of Information Authorization

In order to provide services to you this program may need to obtain information from or share information with other individuals, programs, or providers. This program needs information to provide you services. If this program does not get requested information, or if we cannot share with others who work with you, then this program might not be able to provide you services you may need or this program’s assistance may be hindered. Also, this program may not be able to follow government laws or regulations.

Employer #1

I, ,authorize STEP, Inc. to share information with I know that state and federal privacy laws protect my records. I know:

Why I am being asked to release this information.
I do not have to consent to the release of this information. But not doing so may affect this program's ability to provide needed services to me.
If I do not consent, the information will not be released unless the law otherwise allows it.
I may stop this consent with a written notice at any time, but this written notice will not affect information this program has already released.
The person(s) or agency (ies) who get my information may be able to pass it on to others.
If my information is passed on to others by this program, it may no longer be protected by this authorization.
This consent will end one year from the date I sign it, unless the law allows for a longer period.