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These services are provided in the home and community based supports to assist children and/or adolescents to resolve behavioral problems and function more successfully.

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First Resources Corp.

A Resource For The Community

Disability Services Application

REFERRAL SOURCE CONTACT:

Application Date:

Referral Name, Phone, Email:

Service Area

Adult Day Service

Desired Location

Services Requested

Check all that apply

Adult Day Hab

Adult Day Care

Employment

Check all that apply

Job Development

Discovery

Job Coaching

Small Group Employment

Residential Sites

Check all that apply

Site Home

Individual Respite

Group Respite

Residential Hourly

Check all that apply

SCL Hourly

Habilitation Hourly (UA/UB)

RCF

Keosauqua Location Only

APPLICANT INFORMATION:

Applicant Name:

Address:

Primary Phone #:

Social Security #:

Date of Birth:

Age:

Applicant Gender

Male

Female

Other

Applicant Marital Status

Married

Single

Divorced

Does the person have a legal guardian?

Yes

No

Does the person have a case manager or care coordinator?

Yes

No

Is the person on the Sexual Offender Registry?

Yes

No

Is the person under a mental health committal?

Yes

No

Is the person on probation?

Yes

No

Name & phone number of legal guardian:

Name & phone number of Advocate:

List any founded and or pending criminal charges:

CURRENT INFORMATION:

Where does the person live?

Is the person being or recently been discharged from another provider?

Yes

No

List funding source(s):

If yes, please describe:

List current place of employment:

What is the work schedule?

What is the current wage?

List any work limitations the person has:

List primary form of transportation:

List primary emergency contact (Name/Phone #):

Financial/Educational Information:

Primary Language:

Highest Grade Achieved:

List any educational accommodations received:

Does the person get SSI or SSDI?

Yes

No

Application in process

If yes, how much per month?

Does this person get food stamps?

Yes

No

Does the person have a power of attorney?

Yes

No

Does the person have a burial plan or estate?

Yes

No

Does the person have a representative payee?

Yes

No

Does the person have a conservator?

Yes

No

Medical Information:

Primary Disability:

Other Disabilities:

Is there a "Do Not Resuscitate" Order?

Yes

No

Is the person diabetic?

Yes

No

Is the person an Organ Donor?

Yes

No

Is there a history of seizures?

Yes

No

If yes, can they self-administer the insulin?

Yes

No

Allergies - Please List:

Please list your current medications (or upload file below):

Upload medication list:

Upload File

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What help is needed with medication supports?

Please list insurance information (Medicaid, Medicare and/or private):

Describe any accessibility or balance issues the person may have:

Support Team Information:

Type of Support:

Name/Dr:

Town:

Contact #:

Thank you for your interest in First Resources Corp!

Please call 641-682-8114 or email referral@firstresources.us for any questions

In order to speed up the application process, please send or upload a copy of the following information:

Social History

Upload File

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Current Individual Plan

Upload File

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Copy of guardianship papers

Assessments

Upload File

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Upload File

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Additional Information

Upload File

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Your application has been successfully submitted. Our referral team with be in contact with you soon!

Additional Resources

OUR PARTNERS

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641-682-8114

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