№ lp_2_3_28372
File format: docx
Character count: 2430
File size: 38 KB
Form for intake and referral in the context of social services, collecting personal and medical information for program eligibility.
Note:
Date of Request
Intake Specialist:
Pamela Daniels
Type of Request:
☐Initial ☐ Re-opening
Home:
____ -____ -_____
Work:
____ - _____ -____
Cellphone:
____ - -
Message:
--______
Race:
☐ Asian ☐Black ☐Hispanic ☐Bi-racial ☐Pacific Islander ☐ Caucasian ☐Unspecified ☐Other
Diagnosis:
☐ ID ☐CP ☐Epilepsy ☐Autism ☐Spina Bifida ☐Developmentally Delayed ☐Downs ☐Other
Year:
____________
Social Security Number:
____ - _____ - _____
Legal Status:
☐POA ☐Guardian ☐Legal Custodian ☐Courted Ordered ☐Self
Services Requested:
☐Waiver ☐Group Home| Apartments ☐ICF ☐HDC☐Psychological Evaluation ☐Respite ☐Int. Support ☐Special needs
Assigned PASSE:
☐Empower ☐Summit☐ AR Total Care
Referral Source:
☐ICF ☐Nursing Home ☐ASH ☐Group Home| Apartment☐DCFS ☐APS ☐Community ☐CHC (Title V) ☐PASSE ☐Other
☐ Contact Phone Number:
____ - ____ - ____
Additional Information:
☐ 10 days: ☐ 30 days:☐ 45 days:
Price: 8 / 10 USD
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The product description is provided for reference. Actual content and formatting may differ slightly.
Year:
2021
Region / City:
London
Topic:
Digital Document Solutions
Document Type:
Agreement
Organisation / Institution:
NHS London Procurement Partnership (LPP)
Author:
NHS LPP
Target Audience:
Contracting Authorities
Validity Period:
Not specified
Approval Date:
Not specified
Amendment Date:
Not specified
Year:
2016
Region / city:
United States
Topic:
Healthcare Services, Electronic Visit Verification
Document type:
Guidelines
Organization / institution:
Department of Developmental Services (DDS), Department of Social Services, Gainwell Technology, Sandata Technologies
Author:
Department of Developmental Services (DDS)
Target audience:
DDS providers
Period of validity:
N/A
Approval date:
N/A
Date of amendments:
N/A
Year:
2010
Note:
Region / City
Topic:
Licensure and Certification
Document Type:
Manual
Organization:
Office of Quality Enhancement
Note:
Year
Organization / Institution:
Department of Developmental Services (DDS)
Target Audience:
Participants of the DDS DSW to LPN Certificate Program
Year:
2022
Region / City:
Lewisville, TX
Topic:
Education, Scholarships
Document Type:
Scholarship Application
Organization:
Cups Jars Vessels
Author:
Not specified
Target Audience:
High school seniors planning to attend college or university
Period of Validity:
Applications accepted February 1, 2022 – March 31, 2022
Approval Date:
Not specified
Date of Changes:
Not specified
Note:
Year
Context:
Checklist outlining the required documents and statements for reviewing related party transactions within the DDS Ethics Committee.
Year:
2010
Region / City:
Connecticut
Topic:
Environmental Modification
Document Type:
Checklist
Organization / Institution:
Department of Developmental Services (DDS)
Author:
Unknown
Target Audience:
Individuals requiring environmental modifications
Period of validity:
Ongoing (subject to funding approval)
Approval Date:
08/24/2010
Date of changes:
N/A
Year:
2020
Region / City:
Connecticut, USA
Subject:
Electronic Visit Verification (EVV) implementation
Document Type:
Official memo / guidance
Organization:
Connecticut Department of Developmental Services (DDS)
Author:
DDS Administration
Target Audience:
DDS service providers
Effective Period:
January 1, 2021, onwards
Deadline for Response:
June 30, 2020
Contact Emails:
[email protected]
Systems Mentioned:
SAM system, DDS EVV Portal, Sandata Mobile Connect
Procedure No.:
I.F.PR.007a
Issue Date:
June 30, 2021
Effective Date:
June 30, 2021
Section:
Human Rights and Legal Responsibilities
Approved by:
Jordan A. Scheff
Jurisdiction:
Connecticut, USA
Applicable Entities:
Department of Developmental Services, DDS qualified providers, DDS contractors, volunteer organizations
Purpose:
Implementation and access procedures for the DDS Abuse and Neglect Registry
Definitions Included:
Yes, including examples of abuse and neglect
Confidentiality:
Registry access restricted to authorized personnel
Target Audience:
DDS employees, employers licensed or funded by DDS, volunteer organizations
Legal Basis:
Sections 17a-247a through 17a-247e of the Connecticut General Statutes
Implementation Responsibility:
DDS Abuse and Neglect Registry Administrator
Access Method:
Online Pre-Employment Inquiry System
Note:
Year
Topic:
Medicaid Services, People with Disabilities, Case Management
Document Type:
Guide
Organization / Institution:
Oregon Department of Human Services (ODHS)
Target Audience:
Case Managers, Social Workers, Healthcare Providers
Note:
Year
Year:
2025
Region / City:
Kampala, Uganda
Subject:
Education, Humanities and Social Sciences
Document Type:
Application Form
Institution:
Makerere University
Author:
Makerere University
Target Audience:
Prospective PhD students
Period of Validity:
2026 Intake
Approval Date:
November 17, 2025
Date of Revision:
N/A
Note:
Year
Region / City:
Arkansas, USA
Type of Document:
Intake Form
Institution:
Arkansas Adult Education
Target Audience:
Adult learners
Required Fields:
Personal information, program selection, employment status, contact details
Program Categories:
Adult Education – ABE, Family Literacy, Workplace Literacy, ESL
Disability Status:
Optional disclosure
Military Service Information:
Optional disclosure
Data Sharing Agreement:
Required for participation
Emergency Contact:
Required
Social Security Requirement:
Not mandatory for participation
Enrollment Programs:
WIOA Core Programs, Title 1, Title 3, Title 4
Year:
2026
Region / City:
Washington, USA
Topic:
Social Service Intake Process for Medicaid Long-Term Services and Supports
Document Type:
Informational Guide
Agency:
ALTSA (Aging and Long-Term Support Administration)
Author:
Dru Aubert, Case Management Unit Manager
Target Audience:
Social service professionals, applicants for Medicaid Long-Term Services and Supports
Period of Validity:
N/A
Approval Date:
N/A
Revision Date:
N/A
Institution:
University of Technology Sydney
Program:
Master of Speech Pathology
Document type:
Prerequisite assessment instructions and assessment table
Intake year:
2024
Applicant categories:
Domestic applicants; International applicants
Assessment stage:
Pre-assessment prior to applications opening (domestic only)
Submission timing:
With application after applications open
Submission format:
Word document (.docx)
File naming convention:
LASTNAME-master-speech-pathology-prerequisite-table.docx
Prerequisite subjects:
Human Anatomy; Human Physiology
Level of study required:
Tertiary level
Prerequisite completion timeframe:
Within the past 10 years
Concurrent study:
Not permitted
Academic review cycle:
Annual
Assessment authority:
Academic team
Source type:
University admissions requirements document defining eligibility criteria, submission conditions, and academic content standards for prerequisite subjects for entry to a postgraduate degree.
Note:
Date
Region / City:
Newport News
Topic:
Child Protective Services
Document Type:
Intake Form
Agency:
Newport News Department of Human Services
Target Audience:
Social workers, child welfare professionals
Contextual Description:
A form for reporting suspected child abuse or neglect to the Newport News Department of Human Services, intended for use by social workers and other professionals.
Year:
2023
Region / City:
United States
Subject:
Case intake and home visit documentation
Document Type:
Form
Organization:
USCCB
Author:
Not specified
Target Audience:
Not specified
Period of Validity:
Not specified
Approval Date:
Not specified
Date of Changes:
Not specified
Year:
2023
Region / City:
Grand Rapids, I-Falls
Theme:
Health, Counseling
Document Type:
Intake Form
Organization:
Northland Counseling Center, Inc.
Author:
Northland Counseling Center, Inc.
Target Audience:
Individuals seeking counseling services
Period of Validity:
N/A
Approval Date:
N/A
Date of Changes:
N/A
Year:
2023
Region / City:
California
Topic:
Environmental Impact Assessment, Water Supply Permit
Document Type:
Form
Organization:
State Water Resources Control Board
Author:
Not specified
Target Audience:
Water system permit applicants
Validity Period:
Not specified
Approval Date:
Not specified
Amendment Date:
Not specified
Year:
2023
Region / City:
United States
Subject:
Immigration
Document Type:
Intake Form
Organization / Institution:
Immigration Services
Author:
Unknown
Target Audience:
Individuals seeking immigration assistance
Period of Action:
Not specified
Approval Date:
Not specified
Date of Changes:
Not specified
Context:
A document used to collect biographical and immigration information from individuals applying for immigration services.