Apply to The Guild Apply to The Guild Step 1 of 4 25% Basic Applicant InformationName* First Middle Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Applicant home phone*Applicant cellDate of birth* MM slash DD slash YYYY Age*Religion Height Weight Hair color Eye color Social security number* Medicaid number Medicare number Gender* Male Female Marital status* Single Married Legal status of applicant* Competent major Interdicted Continued tutorship Referral source: How did you learn about The Guild at Raphael Village?* Case manager LRS counselor Case worker Freedom of choice list Friend/community member Other How else did you learn about The Guild?* Funding source* NOW waiver ROW Waiver Supports waiver Private pay Other Other funding source(s)* Support coordination agency Is the Participant receiving other Home and Community Based Waiver Supports?SIL, PCA, Respite, etc. Yes No Please list other Home and Community Based Waiver Supports. Is the participant currently satisfied with the amount of HCBW supports receiving? Yes No Please explain.Is the applicant looking to join The Guild on a full-time or part-time basis?*Please note that placements on a full-time basis are given priority over part-time attendance. Full time Part time If part-time, please mark how many days a week* 1 day 2 days 3 days 4 days How will the Participant get transported to the Center?* Parent/guardian PCA RTA Group home staff How would you characterize the place where the applicant lives?* Group home Independent home or apartment Parent/guardian Please list all who currently live in the applicant’s home.*Click the plus sign to the right to add additional rows.NameRelationshipAge Diagnosis & InterventionsWhat is the applicant’s diagnosis?* Mild ID/DD Moderate ID/DD Severe ID/DD Profound ID/DD Do not know What disabilities other than MR are noted in the applicant’s records?*Check all that apply. Autism Cerebral Palsy Brain injury Seizure disorder/neurological problem Chemical dependency Physical disability Vision/hearing impairment Communication disorder Alzheimer's disease Depression Anxiety Psychiatric diagnoses (Mental illness) Schizophrenia Bipolar Other Additional disabilities*Click the plus sign to the right to add additional rows. Is the applicant currently receiving any interventions?*For example, ABA therapy, OT, speech therapy, behavior modification therapy. Yes No Please list any interventions the applicant is currently receiving.*Click the plus sign to the right to add additional rows. HealthBrief medical overview and overall health:*When was the applicant’s last physical exam?* Within the past year Over one year ago Do not know Past surgeries/hospitalizations:*Does the applicant have any back problems?* Yes No Describe the applicant's back problems.*Does the applicant have diabetes?* Yes No Describe the type of the applicant's diabetes:* Will applicant require glucose monitoring while at the center?* Yes, and the applicant is able to complete this task independently Yes, and the applicant is NOT able to complete this task independently No Will applicant require insulin injections while at the center?* Yes No Does the applicant have any dietary restrictions?* Yes No Explain the applicant's dietary restrictions.*Does the applicant have any allergies?* Yes No Describe the applicant's allergies. How would you describe the applicant’s mobility?* Walks (with or without aids) Non-ambulatory How would you describe the applicant’s vision?* Sees well, with or without corrective lenses Vision problems limit activities, such as reading or travel How would you describe the applicant’s hearing?* Normal in both ears Deficit in left ear Deficit in right ear Describe any medical, physical, psychological, behavioral and/or other needs, conditions or concerns about the applicant that would assist The Guild staff to best support him/her.MedicationList all medications, dosages and times of administration.Click the plus sign to the right to add additional rows. NOTE: It is the policy of The Guild at Raphael Village that medication administration will not be offered during Adult Day Care center hours of operation.MedicationDosageDosage time(s)Purpose Seizure ProfileDoes applicant have a history of seizures?* Yes No Date of last seizure* MM slash DD slash YYYY How often do they occur?* Less than once/month Once/month Once/week More than once/week Do not know How would you describe the seizure?* Grand Mal Petit Mal What does the seizure look like?* Stare blankly Falls to the ground Other Please describe.*Signs or symptoms that may indicate the onset of a seizure:*How long does the seizure usually last?* Any actions found useful in preventing the seizure?*Best way to assist the applicant while they are having a seizure?*Have you ever called 911 or sought other emergency care when applicant is having a seizure?* Yes No Explain:*Behavioral InformationAs per our Guild Member Profile, we are unable to accommodate members who are self injurious or injurious to others or who are at risk of elopement at the center or in the community.Is there any history of abuse (physical, sexual or mental)?* Yes No Explain any history of abuse.*Has the applicant displayed any behavior problems in the home or in previous programs?* Yes No Explain these behavior problems.*Does the applicant elope out of your supervision?* Yes No Explain any elopement out of your supervision.*Does the applicant ever cause injury to him/herself?*For example, hitting self, biting, banging head, scratching or puncturing skin. Yes No Do not know Explain behavior and how often it occurs.*Does the applicant ever interfere with the activities of others?*For example, starting fights, laughing or crying without reason, yelling or screaming. Yes No Do not know Describe behavior and frequency.*Does the applicant ever engage in “uncooperative” or “inappropriate” behaviors?*For example, breaking rules/laws, cheating, acting defiant, or stealing. Yes No Do not know Describe behavior and frequency.*Does the applicant generally throw objects when angered?* Yes No Do not know If yes, about how often does the behavior occur?* Does the applicant generally hit others when angered?* Yes No Do not know If yes, about how often does the behavior occur?* Educational HistoryList any schools attended.*Click the plus sign to the right to add additional rows.Name of schoolDiploma or certificateYear received Has the applicant ever participated in a Day Habilitation Program?* Yes No List any Day Habilitation Programs attended.*Click the plus sign to the right to add additional rows.Name of programDates of attendanceReason for discharge Strengths and Support NeedsPersonal Care SkillsIs applicant capable of managing all personal care needs?*For example, wearing/changing undergarments, cleaning self, menstrual needs. Yes No What support is needed?*What household responsibilities does applicant assume in the home?* Picking up clothes Cleans own room Clean dishes Vacuum Sweep Take out trash Mow lawn Laundry Other None of the above What other household responsibilities does applicant assume in the home?* Money SkillsDoes the applicant handle his/her own money?* Yes No Able to discriminate coin/dollar denomination?* Yes No Can applicant make simple purchases?* Yes No Community Travel SkillsIs applicant able to use public transportation?* Yes No Is applicant RTA/MITS certified?* Yes No Does applicant know his/her way around their neighborhood?* Yes No EmploymentIs the applicant currently participating in Supported Employment?* Yes No Which agency?* Has the applicant previously been employed?* Yes No List where and dates of employment.*Click the plus sign to the right to add additional rows.Location of employmentDates of employment Has the applicant previously served in the American Military?* Yes No American military service:*BranchDates of serviceIs applicant aware that they can receive two HCBW services (i.e. Employment and Day Hab)?* Yes No Is the applicant interested in employment?* Yes No Describe interests.*Interests & PreferencesTypes of activities that the applicant enjoys at home:*Types of activities that the applicant enjoys in the community with family/friends:*Are there any locations in the community that the applicant should avoid due to fears or obsessions?Physical Support Needse.g. Personal care, toileting, feeding, etc.Physical support needs on-site:*Physical support needs in the community:*Learning and Performance CharacteristicsCommunicationWhat is the main way that the applicant communicates?* Uses sounds/gestures Uses sign language Uses key words Speaks unclearly Speaks clearly Social InteractionHow frequently does the applicant initiate conversation or interaction?* Rarely interacts appropriately Polite & appropriate Initiates interactions infrequently Initiates interactions frequently Learning StyleHow does the applicant learn best?* Verbal instruction Modeling from someone else Gestures What are the applicant’s reinforcement needs?* Frequent reinforcement Daily Weekly Rate the applicant for handling criticism/stress.* Resistive/argumentative Withdraws into silence Accepts criticism/does not change Accepts criticism to grow Does the applicant adapt to changes in schedule?* Yes No At what pace can the applicant do activities?* Slow Average Sometimes fast Continual fast Application FeePlease enter the name, confirmation email, and billing address that should be associated with your application fee payment below. Once you submit this application, you'll be redirected to our PayPal online payment portal, where you may complete your non-refundable $50.00 application fee payment.Application fee* Price: Name* First Last Confirmation Email* Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country SignaturesI am requesting admission into The Guild at Raphael Village.Applicant name* First Last How would you like to provide your signature?* I would like to digitally sign my name. I would like to type my signature. Applicant signature*Use the box below to sign your name. Click the refresh icon at the bottom right to clear the box. Reset signature Signature locked. Reset to sign again Applicant signature*Type your full name. This will serve as your digital signature. Parent/guardian name* First Last How would you like to provide your signature?* I would like to digitally sign my name. I would like to type my signature. Parent/guardian signature*Use the box below to sign your name. Click the refresh icon at the bottom right to clear the box. Reset signature Signature locked. Reset to sign again Parent/guardian signature*Type your full name. This will serve as your digital signature. CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
