Get Residential Services Universal Bapplicationb

This guide provides users with clear instructions on how to fill out the Residential Services Universal Application online. It is designed to assist individuals in completing the application accurately, ensuring all necessary information is included for a comprehensive review.

Follow the steps to complete the application.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Begin by filling in the consumer's name and MID number. Ensure that all information is accurate and legible.
3. Provide the date of the application and the date service is needed. This information helps in prioritizing the needs of the consumer.
4. Select the type of referral. Choose from options such as Planned or Emergency Respite, Residential Level 2, 3, 4 Secure, or PRTF.
5. Complete the consumer information section, which includes social security number, date of birth, age, sex, Medicaid number, county, weight, height, current address, and phone number.
6. Fill in the guardian information, including the legal guardian’s name, relationship, address, phone number, and any guardian ad litem details if applicable.
7. Provide details about the primary referral source, including the referring agency, provider agency, agency contact person, and phone numbers.
8. Document clinical/diagnostic information including diagnoses, CALOCUS score, and any history of abuse if applicable.
9. Complete the medical information section, noting any allergies, medical conditions, insurers, and dates of last exams.
10. Outline the presenting problems or reasons for referral, followed by previous treatment interventions noting effectiveness.
11. Include placement history and any current emotional or behavioral problems, providing descriptions and dates of incidents.
12. Detail family information including biological parents, siblings, and any notable family dynamics or social history that is relevant.
13. Fill in the authorized contacts for the consumer and indicate any special conditions or restrictions for visits home.
14. Complete school information, including the last school enrolled, special classes, truancy history, and any current IEP details.
15. Indicate any agency involvement and provide court history, including any criminal record or pending charges.
16. Document the treatment goals, including any history of self-injury, substance abuse, sexualized behaviors, and psychotic behaviors.
17. Finish by obtaining signatures from the treatment service coordinator, supervisor, and clinical approval, and add any additional comments.
18. Finally, review the referral checklist and ensure all necessary documents are attached to the application before submitting.

Complete your application online today to expedite the process and ensure timely support.