Preliminary Application for Services Waiting List

Bittersweet Farms

Preliminary Application for Services
The following information will be used as a tool to assess service interests and placement on the waiting lists at Bittersweet Farms. Bittersweet will be in contact for additional information when the applicant’s name is up for review for an opening in their chosen programs. Please complete this application as fully and accurately as possible.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Basic Information
Name of individual

First NameMiddle NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Place of birth
Is the individual a US citizen?
Current address

Street Address

Street Address Line 2

CityState

Zip Code
In what COUNTY do you reside?
Telephone
If you are your own guardian, please provide your phone number.Format: (000) 000-0000.
Email
If you are your own guardian, please provide your email address.
Gender
Height
Weight
Hair color
Eye color
Identifying marks, if any
Age where developmental delay first noticed
Date Autism Spectrum Disorder officially diagnosed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Complete list of diagnoses.
Please initial you understand that failure to disclose all diagnoses may lead to a 30 day notice to discontinue services.
Guardian Information
Is the person their own guardian? If yes, proceed to Family History section.
Name of guardian (probate court appointed for those 18 years and older)

First NameLast Name
Guardian's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian's telephone
Please enter a valid phone number.Format: (000) 000-0000.
Guardian's email
example@example.com
Guardian's relationship to applicant
Guardian's employer
Guardian's employer telephone
Please enter a valid phone number.Format: (000) 000-0000.
Family History
Mother's name

First NameMiddle InitialLast Name
Father's name

First NameMiddle InitialLast Name
Mother's address if different from applicant or father

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's telephone
Please enter a valid phone number.Format: (000) 000-0000.
Mother's email
example@example.com
Father's address if different from applicant or mother

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's telephone
Please enter a valid phone number.Format: (000) 000-0000.
Father's email
example@example.com
How does the individual get along with:
Mother
Father
Siblings
Emergency Contact

(in addition to parents/guardian)
Name of emergency contact

First NameLast Name
Relationship of emergency contact to individual
Emergency contact's primary phone number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency contact's secondary phone number
Please enter a valid phone number.Format: (000) 000-0000.
Medical History
Name of primary physician

First NameLast Name
Primary physician's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary physician's telephone
Please enter a valid phone number.Format: (000) 000-0000.
Name of dentist

First NameLast Name
Dentist's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of specialist

First NameLast Name
Type of specialist
Specialist's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Medications
Allergies (food, medication, animals, seasonal, other)
Do any allergies require use of EpiPen? If yes, list those allergies here.
Preferred OTC medications

Other - please list
Date of last physical

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current health
Any current medical concerns
Special diet instructions
Please list dates and reasons for any surgeries
Adaptive equipment
Physical limitations
Optional: If applicable, you may provide acuity information in the text field below or by uploading a document.
Optional: Upload Documentation of Acuity

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Personal History

Education

Rows	Name and address	Dates attendeed
School 1
School 2
Graduated from

Latest Employment

Rows	Name and address	Dates employed
Employer 1
Employer 2

Any previous residential placement and reason for transfer
Has the individual ever plead guilty or “ no contest ” to a crime or been convicted of a crime ( felony or misdemeanor ? ) and or have criminal charges pending?

Sources of additional information (any professional, specialist or agency not previously listed who may be able to provide information about the individual)

Rows	Name	Phone	Contact person	Type of services provided
1
2
3
4

Please mark the service(s) the individual would like to receive:
* If applicant selected HUD Housing, please report annual income
*If applicant has selected Social & Recreational Program, please upload IEP/ISP here.

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Funding Sources

Rows	Currently have	Currently applying	Not as this time
Medicaid
Medicare
Level 1 Waiver
Individual Options (I.O.) Waiver
Private Pay

Other funding sources
County Support
Name of county caseworker

First NameLast Name
Caseworker's telephone
Please enter a valid phone number.Format: (000) 000-0000.
Caseworker's email
example@example.com
Date ready to begin services

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Where did you hear about Bittersweet Farms?
Please provide your email

Confirmation Emailexample@example.com
Signature of person completing form
Signature date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to applicant
For questions related to this application, contact us at 419-875-6986 ext. 1230 or tchambers@bittersweetfarms.org.

When you have submitted the application successfully, you will see a "Submitted Successfully" and checkmark verifying that Bittersweet Farms has received your application.
Please verify that you are human
Should be Empty:

Bittersweet Farms

Basic Information

Guardian Information

Family History

How does the individual get along with:

Emergency Contact

Medical History

Personal History

County Support

Signature