Application of Admission | Arkansas Center for Independence

Is the individual applying for placement diagnosed with an intellectual or developmental disability prior to the age of 22?

Yes

*The State of Arkansas requires an individual to be diagnosed with an intellectual or developmental disability prior to the age of 22 in order to receive services. If you are unsure if you qualify for services, please call us at 870.523.8488

aplication

date & services

Date of Application

What services is the applicant seeking?

Day Program

Group Home

In-Home Support

Applicants Full Name

First

Middle

Last

(Enter name exactly as it appears on official document)

Applicants Full Name

Preferred Name(if not First Name)

Former Last Name(s)

Date of Birth

Gender

Male

Female

Birthplace

Are you a U.S. Citizen

Yes

Current Address of Applicant

Number & Street

Apartment Number or P.O. Box

City/Town

State

ZIP Code

Applicant’s Address is the same as Permanent Address of Applicant

Applicant’s Permanent Address

Number & Street

Apartment Number or P.O. Box

City/Town

State

ZIP Code

fieldset1

Telephone

Phone Number of Applicant fieldset

Phone Number of Applicant

Applicant does not have a designated phone.

E-Mail Address of applicant fieldset

E-Mail Address

Applicant does not have a designated email

boxes

What type of insurance(s) is currently available to the applicant?

Medicaid

Medicare

Private insurance

PASSE – Summit Community Care

PASSE - Arkansas Total Care

PASSE - Empower

PASSE - Care Source

Other…

Explain

Referred to ACI by

High School Transitional Meetings

Social Media – News

Friend or Family Member

DHS

PASSE

Other…

Explain

Relationship and Guardian

Have you ever applied at ACI?

Yes

Is the applicant his/her own legal guardian?

Yes

Note: If the applicant is 18 years or older, the applicant is his/her own legal guardian unless legal guardianship has been obtained through the court system.

Explain When

What is your relationship to the applicant?

Mother

Father

Grandparent

Sister or Brother

Legal guardian or representative

Other…

Please Explain…

If the applicant is not their own legal guardian, proof of guardianship will be required upon admission.

Primary Contact Information

Name

First Name

Middle Name

Last Name

Address

Number & Street

Apartment Number or P.O. Box

City/Town

State

ZIP Code

Country

Phone & Email

Phone number

This individual will be the person we contact once the application is received to further collect sensitive information in the application process in order to determine eligibility.

Education

School

High School

Phone Number

Address

City

State

Attended

From

Did the applicant graduate?

Yes

when?

Which type of certificate did the applicant receive?

Diploma

Letter of Completion

Neither

Not Sure

Please attach copy of high school diploma or letter of completion

(Please attach copy of high school diploma or letter of completion)

College/Other Schooling

Graduate

Address

City

State

Attended

From

Graduate

Did the applicant graduate?

Yes

Degree Obtained:

Attach copy of degree or certificate

One file only.
256 MB limit.
Allowed types: gif jpg jpeg png txt pdf doc docx tar zip.

Education – Continued

Was the applicant in special education classes?

Yes

Is the applicant currently attending a school or program?

Yes

Where?

Please list other agencies, schools, training facilities and programs (with dates) that have assisted the applicant in the past

Diagnosis

Primary Diagnosis(Check only one)

Intellectual Disability

Seizures / Epilepsy

Autism

Down Syndrome

Cerebral Palsy

Traumatic Brain Injury

Other

Enter other…

Secondary Diagnoses(Check all that apply)

Intellectual Disability

Seizures / Epilepsy

Autism

Down Syndrome

Cerebral Palsy

Traumatic Brain Injury

Other

Enter other…

At what age did the onset(s) occur?

At what age was the diagnosis made?

Physician who diagnosed

Phone Number

Date of last psychological exam

Please provide copy

One file only.
256 MB limit.
Allowed types: jpg jpeg png txt pdf doc docx tar zip.

Last combined IQ score

Medical History

Family Doctor

Phone Number

Dentist

Phone Number

Eye Doctor

Phone Number

Medical History - Continued

Does the applicant use or need special equipment(Check all that apply)

Walker

Wheelchair

Vision Correction

Hearing Aids

Leg Braces

Crutches

Dentures

Other

Enter other…

Is the applicant currently taking or prescribed any medications

Yes

Please list all medications and dosage

Is the applicant allergic to any substance(s), food, or medicine(s):

Yes

Please explain

Is a special diet required?

Yes

Please explain

Can the applicant physically administer his/her medication?

Yes

Prompting needed?

Yes

Has the applicant ever had any medical procedures or major surgeries?

Yes

Please list type of surgery and date:

Has the applicant ever had any significant injuries?

Yes

Please explain

If female, has the applicant ever been pregnant?

Yes

Please state the number of pregnancies and explain the outcome of each

Are medical conditions being controlled completely with medication?

Yes

Please state the condition, and why you indicate medication(s) have not worked

Behavior

How does the applicant express him/herself when they are feeling:

Happy

Angry

Sad

Afraid

Upset

Pain

Does the applicant have any self-stimulatory behaviors?

Yes

Please Explain

Behavior-checkbox

Does the applicant have any of the following challenging behavior problems? (Check all that apply)

Hits others

Throws Objects

Self-Harm

Pinches

Destroys Property

Suicidal Tendencies

Homicidal Tendencies

Spits on Others

Inappropriate Touching

Depression

Screaming

Elopes (Runs Away)

Biting

Head Banging

Other…

Enter other…

Please explain all checked behaviors further:

Behaviour-radio

Does the applicant have an adverse reaction to authority?

Yes

Please Explain How

Has the applicant had any inpatient behavioral health admissions?

Yes

so, please list where, date, and the reason for admission for all occurrences.

Has the applicant ever had any legal issues, charges, or arrests, including any that are currently pending?

Yes

Please Explain

Is the applicant a registered sex offender?

Yes

Physical Abilities

Physical Abilities - Continued

Of these skills, which do you think the most assistance will be needed? (Check all that apply)

Walk

Talk

See

Hear

Reading

Spelling

Writing

Speech

Grooming

Toileting

Laundry

Housekeeping

Cooking

Feeding Self

Work Independently

Personal Safety

Telling Time

Budgeting

Making Change

Use Telephone

Time Management

Medication Management

Rate all of the following:

1-Unable to complete | 2- Needs Assistance | 3 – Complete on own WITH prompting | 4 – Complete on own WITHOUT prompting

Rate all of the following:
Walk Talk See Hear Reading Spelling Writing Speech Grooming Toileting Laundry Housekeeping Cooking Feeding Self Work Independently Personal Safety Telling Time Budgeting Making Change Use Telephone Time Management Medication Management

Please further explain individuals ‘greatest needs:

Financial

Applicant’s Income Sources (Must Complete to apply for day services)

Financial-step1

Employment $

Savings $

SSI $

SSA $

Trust Fund $

Other $

Name source $

Does the applicant have any outstanding financial obligations?

Yes

Has a trust fund been established for the applicant?

Yes

Where?

Is the applicant currently employed?

Yes

Where?

Business Address:

Number & Street

City/Town

State

ZIP Code

Financial-step2

Supervisor Name

Contact Number

Financial – Continued

Mother’s \ Guardian Income Sources (Complete only if applicant will need financial assistance from family)

Mother Financial1

Employment $

Savings $

Investments $

Rent Income $

SSI $

SSA $

Trust Fund $

Child Support $

Other $

Name source $

Do you have any outstanding financial obligations?

Yes

Do you rely on the applicants SSI to make monthly household payments?

Yes

Are you able to help the applicant financially with the cost of the program?

Yes

Are you currently employed?

Yes

Where?

Business Address:

Number & Street

City/Town

State

ZIP Code

Mother Financial - 1

Supervisor Name

Contact Number

Financial – Continued

Father Financial

Father’s \ Guardian Income Sources (Complete only if applicant will need financial assistance from family)

Father Financial-1

Employment $

Savings $

Investments $

Rent Income $

SSI $

SSA $

Trust Fund $

Child Support $

Other $

Name source $

Do you have any outstanding financial obligations?

Yes

Do you rely on the applicants SSI to make monthly household payments?

Yes

Are you able to help the applicant financially with the cost of the program?

Yes

Are you currently employed?

Yes

Where ?

Business Address:

Number & Street

City/Town

State

ZIP Code

Father Financial-2

Supervisor Name

Contact Number

Emergency Contact

(Legal guardian will be contacted first – Secondary Contact Only)

Emergency Contact-1

Name

Relationship to Applicant

Current Address:

Number & Street

Apartment Number or P.O. Box

City/Town

State

ZIP Code

Emergency Contact-2

Main Phone Number

Cell Phone Number:

ACKNOWLEDGEMENT

I acknowledge that all the information provided in this application is true, accurate, and complete to the best of my knowledge. By signing below, I confirm that this application has been completed by the applicant, their legal guardian, or legal representative as indicated.

Applicant-name

Applicant’s Printed Name:

Legal Guardian / Representative Printed Name:

Applicant-sign-date

Applicant’s Signature

Sign above

Date

Title of Legal

Legal Guardian

Legal Representative

sign-date

Signature

Sign above

Date

Services

Applicant’s Income Sources (Must Complete to apply for day services)

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