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Mission Statement: At Mid-Step Services, we are dedicated to providing residential, vocational,
educational and recreational services to people with intellectual disabilities in a caring,
supportive environment where each individual is encouraged to reach his or her highest
A. IDENTIFYING INFORMATION
District of Columbia
Zip / Post Code
Social Security Number
Date of Birth
Does applicant have a Guardian?
List family members applicant has interaction with:
Indicate Services Requested (Check One)
Indicate applicant’s place of residence and/or services (Check One)
If living in a residential facility, please list it:
Why is placement being requested?
Have other potential placement been investigated? If so, list place and location
B. DISABILITY DESCRIPTION
Which of these disabilities are the applicant's primary disability? (list a letter)
What is the applicant's IQ?
Date of last IQ testing
When was the diagnosis first made?
From the most recent assessment available, indicate applicant’s level of intellectual functioning:
Does applicant have a psychiatric diagnosis ? (e.g. – ADHD, bi-polar, personality disorder, etc.)
Does applicant have known allergies?
If Yes, indicate:
Does the applicant have a history of epilepsy/seizure disorders? If yes, check what applies.
In the past year, how frequently has applicant experienced seizures that involve loss of awareness and/or consciousness? (Check One)
Date of last observed seizure:
Indicate whether or not any of these medical conditions apply
If Yes, is applicant insulin dependent?
List any medications along with dosages the applicant is taking:
List the doctor’s name, address and telephone number for the above prescribed medications listed:
Does applicant receive on-going medication by injection?
Which best describes the assistance level applicant requires when taking prescription medication?
Was the applicant hospitalized for a medical problem in last year?
Date of hospitalization:
Does applicant require direct care staff be trained in special health care procedures (e.g. – ostomy care, positioning adaptive devices)
If yes, specify:
Does applicant require special diet planned by dietician, nutritionist or nurse (e.g.- high fiber, low-calorie, low-sodium, pureed, ground, etc.)
If yes, specify:
Check which best describes the applicant’s sleep pattern:
Physical description of applicant:
Mark any services the applicant currently receives:
List the name, address, and telephone number to all that apply above:
D. SENSORY/MOTOR SKILLS
Does applicant wear dentures?
Does applicant have glasses?
Which best describes applicant’s vision? (Check One)
How does applicant transfer weight: (Check One)
Check responses that best describes applicant’s typical level of mobility:
Indicate whether or not applicant:
a. Can roll from back to stomach?
b. Can pull self to stand?
c. Can walk up and down stairs by alternating feet from step-to-step?
d. Can pick up a small object ?
e. Can transfer an object from hand-to-hand?
Does applicant wear hearing aids?
Which alternative best describes applicant’s hearing? (Check One)
E. SOCIAL/BEHAVIORAL ADJUSTMENT/
Does applicant like to participate in group activities?
Does applicant initiate interaction with others?
Can applicant attend to task?
Approximately how long?
Is applicant aware of the following?
Check which skills the applicant can accomplish:
Indicate whether or not applicant can perform each of
the following skills/tasks/communication directives:
a. Knows how to read and write?
b. Understands the concept of money?
c. Understands simple addition/subtraction?
d. Knows how to use the stove/oven/microwave?
e. Knows how to prepare foods that do not require cooking?
f. Knows how to shop for meals?
g. Knows how to use the telephone?
h. Understands one-step directions (e.g.- “Put on your coat?” )
i. Understands two-step directions (e.g. “Put on your coat and then go outside?“)
j. Indicates a “Yes” or “No” response to a simple question?
k. Knows how to make the bed?
l. Knows how to clean a room?
m. Knows how to do laundry?
n. Knows safety in crossing streets in the neighborhood?
o. Knows how to use public transportation for a simple direct trip?
p. Knows what leisure time is?
Indicate the frequency of each behavior over the last 12 months where
None means no incidents, Occasionally means less than once a month, Frequently means several times a week, and Daily once a day or more:
a. Has tantrums or emotional outbursts:
b. Damages own or other’s property:
c. Physically assaults others:
d. Disrupts other’s activities:
e. Is verbally or gesturally abusive:
f. Is self-injurious:
g. Resists supervision:
h. Runs or wanders away:
k. Displays sexually inappropriate behavior:
j. Eats inedible objects (PICA):
l. Disturbs property:
As a result of any behavior(s) what corrective measures are used? (Please describe)
As best you can, indicate how independently applicant typically performs each activity:
c. Taking a shower/bath:
d. Brushing teeth/cleaning dentures:
e. Chewing/swallowing food:
g. Brushing/combing hair:
h. Selecting clothes appropriate to weather:
k. Drinking from a cup or glass: