Date:_____________                                   Language preference: _______________

Name:  ______________________________                               DOB: _________  _____   

Address: ___________________________________

City/State/Zip: ___________________________________________

Contact Person: ______________________            Contact #: ___________________

Primary disability: ______________________________________________________________________________

______________________________________________________________________________

Medicaid Number:_____________________________________

Referred by:____________________________________________

Circle current health insurance:

 

Texas Home Living

Metrocare

HCS

Molina

Amerigroup

Superior

Children’s

Cigna

TMHP

Other:

 

Circle the assistance needed:

Bathing

Medication assistance

Dressing

Toileting

Meal prep

Transferring

Feeding/eating

Ambulation

Exercise

Cleaning

Grooming

Laundry

shaving or oral care

Shopping

Routine hair or skin care

Escorting

Positioning

Other:

 

 

 

 

 

 

 

Does the individual use any adaptive equipment? Ex: Hoyer lift, wheelchair, walker, cane, etc._______________________________________________________________________________________________________  _________________________________________________

Please note anything else that may be helpful with obtaining assistance for this individual. __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________