Date *

MM

DD

YYYY

Client's Name *

First Name

Last Name

Client's DoB *

MM

DD

YYYY

Legal Status *

If “Incompetent”, give name and address of court appointed legal guardian below.

Competent

Incompetent

Guardian/Contact *

First Name

Last Name

Guardian/Contact Phone *

(###)

###

####

Funding Type *

Med Waiver (APD)

Private Pay

Support Coordinator *

First Name

Last Name

Coordinator's Phone *

(###)

###

####

Ambulatory Status *

Check all that apply.

Wheelchair, Transfer

Wheelchair, Non-Transfer

Walks with steady gait

Walks with unsteady gait

Uses cane/crutch/walker

Other

None

Ability to Live Independantly *

Yes, independant

No, not independant

With some support