APPLICATION FOR ADULT SERVICES 

PROGRAMS REQUESTED (Check all that apply):

Residential Programs

£ Group Homes (Genesis/Pearl Street)

£ Intensive Supportive Apartments

£ Supportive Apartments

Case Management

£ Intensive Case Management

£ Supportive Case Management

£ Dual Recovery Case Management

£ Supported Housing

Psychosocial Club/Vocational Rehabilitation

£ East Side Center

£ Project C.H.O.I.C.E.

 

CLIENT INFORMATION:

Name: _______________________________________       Date of Referral: _________________________________

Address: _____________________________________  City, State, Zip: __________________________________

Phone (H): ___________________ Phone (W): _______________ Sex: __________ DOB: ___________________

Social Security: ________________________________         Medicaid/Medicare #: ____________________________

Emergency contact: _____________________________ Relationship: _______________ Phone: ______________

Please check all that apply:

                £                  Functionally Disabled due to a Mental Illness      

£                  SSI or SSDI Enrollment due to a Mental Illness

£                  Functionally Disabled in the Areas Indicated:      

£ Self-Care                              £ Activities of Daily Living        £ Social Functioning                              £ Inability to Complete Tasks        £ Self-Direction                        £ Economic Self-Sufficiency

£                  Regular and Ongoing Reliance on Psychiatric Treatment, Rehabilitation, and Supports

Referral Source: ______________________________ Name: ________________  Relationship: ______________

Address: __________________________________________  Phone: _________________ Fax: ______________

Reason for referral at this time (please state specifically how these services will benefit the applicant): __________ ____________________________________________________________________________________________

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PSYCHIATRIC INFORMATION:

Clinical Treatment Provider: ______________________________________________ Phone: ________________

Therapist: _______________________________________  Psychiatrist: _________________________________

Diagnosis:         Axis I: _________________________________________________________________________

                        Axis II: ________________________________________________________________________

                        Axis III: _______________________________________________________________________

                        Axis IV: _______________________________________________________________________

                        Axis V: _______________________________________________________________________

Medications (please list dosage and attach additional sheets if necessary): _________________________________

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Does the applicant take medications as prescribed?   Yes   £     No   £

 

SUICIDE/HOMICIDE RISK:                       Yes  £                       No  £                    Unknown   £

Please describe recent suicidal ideation, suicide attempts or homicidal ideation: _______________________

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Please describe past history of suicidal ideation, suicide attempts or homicidal ideation: _________________

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Early warning signs of decompensation: ______________________________________________________

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PSYCHIATRIC HOSPITALIZATION:        Unmet Needs   £         Needs Met   £    Unknown   £

Currently inpatient? Yes  £    No   £      Admit date: _________________   Anticipated D/C date: _____________

Please list any previous psychiatric hospitalizations: __________________________________________________

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MENTAL HEALTH TREATMENT:           Unmet Needs   £         Needs Met   £    Unknown   £

Please list any previous outpatient treatment, including current: _________________________________________

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Brief history of illness: _________________________________________________________________________

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Does the applicant have a history of violence towards self or others? Yes  £    No   £        If yes, please explain.

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HEALTH CARE:                                           Unmet Needs   £         Needs Met   £    Unknown   £

Primary Care Provider: __________________________________________________         Phone: ______________

Medical Conditions: ____________________________________________________________________________

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Allergies: ____________________________________________________________________________________

Has a health care proxy been executed: Yes  £    No   £

Has an advance directive been executed: Yes  £              No   £                     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUBSTANCE ABUSE:                                  Unmet Needs   £         Needs Met   £    Unknown   £

Please list past and present use and treatment: _______________________________________________________

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Length of sobriety: ___________________________ Substance of choice: ________________________________

Treatment provider: ____________________  Clinician: ___________________  Phone: ____________________

 

LEGAL INVOLVEMENT:                                        Unmet Needs   £        Needs Met   £     Unknown   £

History of arson, legal or criminal involvement? Yes   £    No   £           Current charges pending? Yes £     No £

Currently on probation? Yes £  No £                                                            Currently on parole? Yes £      No £

Please explain: ________________________________________________________________________________

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Probation or Parole Officer: _________________________________________ Phone: ______________________

 

FINANCIAL MANAGEMENT:                    Unmet Needs   £         Needs Met  £     Unknown   £

Check if applicable:                   Medicaid £         SSI £               SSD £                         PA £             

Application pending for:             Medicaid £         SSI £                    SSD £                           PA £

Medicaid #:_________________ Medicare #:______________________ Other Insurance:____________________

Please list any financial management needs, including rep payee status and income source: ___________________

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LIVING ARRANGEMENT:                                      Unmet Needs   £         Needs Met   £    Unknown   £

Homeless, or at risk of homelessness?   Yes  £     No  £

Please list current living arrangement, including any current or pending subsidies: __________________________

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Many programs require group living and/or group participation.  Please assess applicant’s ability to tolerate such a structure: ____________________________________________________________________________________

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VOCATIONAL/EDUCATIONAL FUNCTIONING:  Unmet Needs  £      Needs Met   £       Unknown   £

Please list vocational/educational goals, strengths, barriers to employment/school participation and work history:  ____________________________________________________________________________________________

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TRANSPORTATION:                                   Unmet Needs   £         Needs Met   £    Unknown   £

Please list current transportation needs: _____________________________________________________________

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SOCIAL SUPPORTS:                                    Unmet Needs   £         Needs Met   £     Unknown  £

Natural supports: ______________________________________________________________________________

Leisure time activities: __________________________________________________________________________

Social clubs/support groups: _____________________________________________________________________

Identified needs: _______________________________________________________________________________

 

Is individual aware of this referral?         Yes  £             No £

Is individual interested in services?         Yes  £                         No £

Please list client strengths and skills: _______________________________________________________________

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SERVICE NEEDS:                 Yes                  No                    High Priority                 Low Priority

Psychiatric Services:                  £                            £                            £                                            £

Medication Management:           £                            £                            £                                            £

Substance Abuse Services:        £                            £                            £                                            £

Living Arrangements:                £                            £                            £                                            £

Self-Care:                                 £                            £                            £                                            £

Legal:                                       £                            £                            £                                            £

Benefits/Financial:                     £                            £                            £                                            £

Transportation:                          £                            £                            £                                            £

Medical Services:                      £                            £                            £                                            £

Work/School:                            £                            £                            £                                            £

Social/Family Relationships:        £                            £                            £                                            £

Crisis/Safety Planning:               £                            £                            £                                            £
Other (describe):                                  

   

ADDITIONAL COMMENTS:

Please add any additional comments: ______________________________________________________________

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Required information:                                                                                                        Please send form and information to:

£            Consent for release of information                                                                    SPOE Coordinator

£            Psychiatric evaluation (most recent; for Residential, within 1 year)            Office of Community Services

£            Treatment plan (most recent)                                                                             230 Maple Street

£            Admission/discharge summaries (most recent)                                              Glens Falls, NY 12801

£            Physical exam with T.B. (Residential, South Street Center only) Phone: (518) 792-7143

£            Functional assessment survey (Residential only)                                          Fax: (518) 792-7166

£            Signed physician authorization for restorative services (Residential only)