Initial Application and Assessment

Client Name

Program Interested In

DOB

Age

Marital Status

CVRC CPC

Preferred Language

Ethnic Background

Transportation

Street Address

City

Zip Code

Living Arrangements (Parents, Family Member, SNF, CCF, RCFE, FHA, or NH)

Email Address

Emergency Contacts #1

Emergency Contacts #2

Emergency Contacts #3

Doctor's Name

Health: Any medical problems or physical limitations, cultural/religious or technical assistance concerns:

Mark All That Apply:

If Other:

Communication Skills:

Describe communication skills: (Verbal, ASL, non-verbal, gestures, sounds, 1-2 word or full sentences, etc)

Reinforcement Inventory: (List items that can be used to reinforcement positive behaviors. IE: one on one time with a favorite person, tangible or edible items, movies, shopping, etc.)

Conserved:
 Yes No

If yes, name of the conservator:

Completed By:

Date:

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