REDI APPLICATION Choose your ProgramDDS WaiverSupportive EmploymentThink 1stTicket to WorkMoney Follows the PersonBenefit Planning Application of AdmissionDate MM slash DD slash YYYY Identifying InformationFull Name(Required)Address(Required) Street Apt or Suite City State 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 Zip Code Home Phone NumberCell Phone NumberTTY Phone NumberEmail Address(Required) Birth Date: MM slash DD slash YYYY AgeBirthplaceSex M F HeightWeightEDI(How do you prefer to identify as he, she, them, they)Language English Other OtherDo you need language accommodations? Yes No (If yes, please describe)Do you have a criminal history? Yes No (If yes, please explain)Do you have a will/trust? Yes No Are you your own guardian? Yes No (if no, please provide your guardian information) Guardian Name(Required)Guardian Email Address(Required) Guardian Home Phone NumberGuardian Cell Phone Number(Required)Guardian Work Phone NumberGuardian Address(Required) Street Name City State 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 Zip Code Do you have guardianship papers? Yes No Is the participant currently in a hospital, residential facility, or nursing home? Yes No Discharge Date MM slash DD slash YYYY Address of FacilityDo you have a discharge summary plan? Yes No Parent/Guardian NameParent/Guardian Street Address City State 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 Zip Code Emergency Contact PersonPhone NumberMother’s NameOccupationWork AddressWork Phone NumberMother’s Email Address Father’s NameOccupationWork AddressWork Phone NumberFather’s Email Address Do you live with your parents? Yes No (If no, Please answer the following questions)With whom do you live?RelationshipWork AddressWork Phone NumberOccupationMarital Status of Parents Married Separated Divorced Widowed Never Married List names of all siblingsNameBirthdateRelationship Add RemoveHealth Insurance (check all that apply) Are you attributed to PASSE? Yes No (If yes, please provide the following information) Name of PASSEPASSE NumberName of PASSE Care CoordinatorPASSE Care Coordinator Phone NumberPASSE Care Coordinator’s Email AddressMedicareMedicare NumberPart A/Part B/Part D Date began receivingSupplemental PolicyPolicy NamePolicy NumberMedicaidMedicaid Program NameMedicaid NumberEmployer Health InsuranceHealth Insurance NamePolicy NumberMedical InformationHave you ever had a psychological evaluation? Yes No Date MM slash DD slash YYYY (If yes, please list date) Please Check ALL that apply:Do you currently have a Psychological Evaluation Independent Assessment (IA) ICAP Are you currently seeing a therapist? Yes No (If yes, please provide contact information)NameAddressPhone NumberTherapist Email Address Name of Primary Care PhysicianPhone NumberOffice Address Street Name City State Zip Code NPI NumberPlease list all physicians that are currently treating you.Physician's NameAddressPhone NumberNPI#What are you seeing this doctor for? Add RemoveDate of Last Physical MM slash DD slash YYYY Date of Last Eye Exam MM slash DD slash YYYY Date of Last Hearing Exam MM slash DD slash YYYY Are vaccinations current?Date Received MM slash DD slash YYYY Do you have a copy of your immunization records? Yes No Do you have a copy of your COVID immunization? Yes No Primary DiagnosisSecondary DiagnosisKnown AllergiesDo you take medications? Yes No (if yes, please list medications, dosage & frequency)Medication NameDosageFrequencyWhat are you taking this medication for? Add RemoveWhat pharmacy do you currently use?Pharmacy NamePharmacy AddressPharmacy Phone NumberDentistNameAddressTelephone NumberAny dental issues?Do you have any medical/physical limitations? Yes No If yes, please describeDoes the participant have any of the following adaptive equipment?WheelchairYesNoHow Long?Medical SupplierYear PurchasedDoes the participant have any of the following adaptive equipment?WalkerDoes the participant have any of the following adaptive equipment?StanderDoes the participant have any of the following adaptive equipment?Car SeatDoes the participant have any of the following adaptive equipment?GlassesDoes the participant have any of the following adaptive equipment?Hearing AidDoes the participant have any of the following adaptive equipment?Hand SplintsDoes the participant have any of the following adaptive equipment?TLSO (Back Brace)Medical Supplier NameMedical Supplier Phone NumberMedical Supplier AddressDoes the participant currently receive any therapy? Yes No If yes, what type, when, and how often?If not, have you received therapy in the past? Yes No If yes, where?Please explain the following skills:(Required)BathingTotally IndependentIndependentNeeds AssistanceExplain if needs assistancePlease explain the following skills:(Required)ToiletingPlease explain the following skills:(Required)DressingPlease explain the following skills:(Required)Teeth brushingPlease explain the following skills:(Required)Hair CarePlease explain the following skills:(Required)FeedingPlease list any upcoming appointments that you have already scheduled:Financial InformationBenefits received SSI SSDI SSA Amount of Benefits received(Monthly) Do you currently have a Rep Payee? Yes No Name of Rep PayeeIf yes please providePhone Number for Rep PayeeEmail Address of Rep Payee If no, would you be interested in CADS being your Rep Payee? Yes No Other benefits receivedHousingSNAPSNAP amount (monthly)Renewal Date (for housing & SNAP)Other ResourcesDo you have any of the following accounts? (Please check all that apply) ABLE Account IDA Trust Account Special Need Trust Account Current Pass Plan Education What is your highest grade completed?(Required)Primary or Secondary SchoolSchool AttendedCompleted (Yes or No)Certificate Received (Did Not Complete or Completed )What is your highest grade completed?(Required)High School(Diploma or GED)What is your highest grade completed?(Required)Vocational/ Technical College(Some Training or Certificate)What is your highest grade completed?(Required)College(Some College Degree or Graduate Degree)Have you attended any other schools or day programs? Yes No (If yes, please list places & dates attended)ProgramDates Attended Add RemoveCurrent Employment Status (check one):(Required) Not working Working part-time Working full time Self Employed Volunteer Are you on the Ticket to Work Program (TTW)? Yes No (If yes) Who is your Employment Network (EN)?EN NameEN Phone NumberEN Email AddressHave you completed your trial work level? Yes No EmployerDate of hire MM slash DD slash YYYY ListHourly WageWeekly hoursMonthly HoursMonthly IncomeAny other sources of incomeAmountDo you have a vocational rehabilitation counselor? Yes No If yes, please provide contact informationNameTelephone NumberEmail Address Please provide any other comments and/or additional needs regarding the applicants STRENGTHS & NEEDS:What are some goals you would like to achieve?Name of person completing this application, if other than the applicant(Required)Relationship to Applicant or Title(Required)Referral Source(Required)Signature of Applicant/Guardian(Required)Date(Required) MM slash DD slash YYYY OFFICE USE ONLY Date Interviewed MM slash DD slash YYYY Date Admitted MM slash DD slash YYYY Date Declined MM slash DD slash YYYY CEO or Designated RepresentativeDate Declined MM slash DD slash YYYY Applicant’s Name(Required)Date of Birth(Required) MM slash DD slash YYYY I, as parent or legal guardian ofApplicant’s Namegive my consent forName of Facility to Release Recordsto release all records pertaining toApplicant’s Nameso he/she can be considered for admission to Central Arkansas Disability Services Facility. Please send records to: Central Arkansas Disability Services 201 West Broadway Street, Suite M North Little Rock, Arkansas 72114 Telephone Number: (501) 537-1080 Fax Number: (501) 537-1082 Signature of Parent/Guardian(Required)Date(Required) MM slash DD slash YYYY Signature of Witness(Required)Date(Required) MM slash DD slash YYYY
