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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.

641-682-8114

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First Resources Corp.

A Resource For The Community

RCF Application

REFERRAL SOURCE CONTACT:

Application Date:

Referral Name, Phone, Email:

RCF Services Are Available At The 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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Progress Notes

Medical Information

Upload File

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Upload File

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

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