Therapy Services - Case History Form

Name(Required)
MM slash DD slash YYYY
Address(Required)

Conservator

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

Program Interest

Which program are you interested in? Please check all that apply:(Required)
What are your overall hopes/outcomes for therapy?
List any medical diagnoses that the individual has.
Is the individual CURRENTLY receiving any of these therapies? If yes, please state which therapies:
Describe the person’s daily life routine and self-care abilities: are they independent? What do they need help with?
Is the individual verbal? Can they independently request wants/needs using language? Do they use assistive technology to communicate?
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
List any behaviors that interfere with daily living that are of concern (i.e. aggression, property destruction, self-injury, elopement, stimming, etc.)
Please list any other information you would like us to know.

Coverage Information

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