Therapy Services - Case History Form

Name
MM slash DD slash YYYY
Address

Conservator

Does the individual have a conservator/guardian?
If so, please provide the name:

Program Interest

Which program are you interested in? Please check all that apply:
What is your preference for place of service?
Please explain why the individual is requesting therapeutic services. What are they hoping to gain?
Is the individual currently receiving therapy, or have they had this type of therapy in the past? If so, when and by who?
List any medical diagnoses that the individual has.
Housemates? Level of Independence? Individuals within his/her circle that are important to him/her?
Describe the person’s daily life routine.
Does the individual have a job or want to pursue future employment?
Is the individual verbal? Can they independently request wants/needs using language?
Does the individual use a specific type of assistive technology to communicate? If so, what do they use?
Describe self-care abilities. (Showering, toileting, dressing, laundry, etc.)
Describe household maintenance abilities. (dishes, vacuuming, cleaning bathroom, etc.)
Explain eating habits of the individual (picky eater, difficulty swallowing, over-eating, eating with utensils, eating non-food items, etc.)
Is the individual afraid of anything? Do they not want to be around certain people or things?
Are there concerns about the individual’s safety awareness?
Does the individual drive, use public transportation, etc.?
What does the individual like to do for fun? What are their hobbies and interests? What activities do they enjoy?
Please describe the individual’s social life. Do they have friends? Do they enjoy being around others and engaging in group activities?
Can the individual walk, or do they require assistance navigating their daily life? Please explain

Maladaptive Behaviors

Please describe the following behaviors (intensity, duration, etc.). If they are not relevant, please type N/A.
(hitting, spitting, kicking, biting, pushing etc.)
(head-banging, picking skin, etc.)
(punching walls, breaking items, etc.)
(running away from a designated area, home, or family, etc.)
(Repetitive or unusual movements like hand flapping)
(inappropriate touching, etc.)
Please list any other behaviors that are of concern

Insurance Questions

Medicaid Waiver:
Does the individual qualify for Medicaid Wavier services?
If so, for which Medicaid waiver services has funding been applied or approved?
Insurance
Is the individual currently covered by any insurance?
If yes, what is the insurance Company?

Contacts/Information

Please provide contact information for the following:
Primary Care Physician
Name
Consent for Referral