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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Applicant home phone*Applicant cellDate of birth* Date Format: MM slash DD slash YYYY Age*ReligionHeightWeightHair colorEye colorSocial security number*Medicaid numberMedicare numberGender*MaleFemaleMarital status*SingleMarriedLegal status of applicant*Competent majorInterdictedContinued tutorshipReferral 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 Supports waiver Private pay Other Other funding source(s)*Support coordination agencyIs the Participant receiving other Home and Community Based Waiver Supports?SIL, PCA, Respite, etc.YesNoPlease list other Home and Community Based Waiver Supports.Is the participant currently satisfied with the amount of HCBW supports receiving?YesNoPlease 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 timePart timeIf part-time, please mark how many days a week*1 day2 days3 days4 daysHow 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 homeIndependent home or apartmentParent/guardianPlease 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/DDModerate ID/DDSevere ID/DDProfound ID/DDDo not knowWhat 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.YesNoPlease 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 yearOver one year agoDo not knowPast surgeries/hospitalizations:*Does the applicant have any back problems?*YesNoDescribe the applicant's back problems.*Does the applicant have diabetes?*YesNoDescribe 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 independentlyYes, and the applicant is NOT able to complete this task independentlyNoWill applicant require insulin injections while at the center?*YesNoDoes the applicant have any dietary restrictions?*YesNoExplain the applicant's dietary restrictions.*Does the applicant have any allergies?*YesNoDescribe the applicant's allergies.How would you describe the applicant’s mobility?*Walks (with or without aids)Non-ambulatoryHow would you describe the applicant’s vision?*Sees well, with or without corrective lensesVision problems limit activities, such as reading or travelHow would you describe the applicant’s hearing?*Normal in both earsDeficit in left earDeficit in right earDescribe 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?*YesNoDate of last seizure* Date Format: MM slash DD slash YYYY How often do they occur?*Less than once/monthOnce/monthOnce/weekMore than once/weekDo not knowHow would you describe the seizure?*Grand MalPetit MalWhat 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?*YesNoExplain:*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)?*YesNoExplain any history of abuse.*Has the applicant displayed any behavior problems in the home or in previous programs?*YesNoExplain these behavior problems.*Does the applicant elope out of your supervision?*YesNoExplain 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.YesNoDo not knowExplain 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.YesNoDo not knowDescribe behavior and frequency.*Does the applicant ever engage in “uncooperative” or “inappropriate” behaviors?*For example, breaking rules/laws, cheating, acting defiant, or stealing.YesNoDo not knowDescribe behavior and frequency.*Does the applicant generally throw objects when angered?*YesNoDo not knowIf yes, about how often does the behavior occur?*Does the applicant generally hit others when angered?*YesNoDo not knowIf 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?*YesNoList 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.YesNoWhat 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?*YesNoAble to discriminate coin/dollar denomination?*YesNoCan applicant make simple purchases?*YesNoCommunity Travel SkillsIs applicant able to use public transportation?*YesNoIs applicant RTA/MITS certified?*YesNoDoes applicant know his/her way around their neighborhood?*YesNoEmploymentIs the applicant currently participating in Supported Employment?*YesNoWhich agency?*Has the applicant previously been employed?*YesNoList 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?*YesNoAmerican military service:*BranchDates of serviceIs applicant aware that they can receive two HCBW services (i.e. Employment and Day Hab)?*YesNoIs the applicant interested in employment?*YesNoDescribe 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/gesturesUses sign languageUses key wordsSpeaks unclearlySpeaks clearlySocial 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 instructionModeling from someone elseGesturesWhat are the applicant’s reinforcement needs?*Frequent reinforcementDailyWeeklyRate the applicant for handling criticism/stress.*Resistive/argumentativeWithdraws into silenceAccepts criticism/does not changeAccepts criticism to growDoes the applicant adapt to changes in schedule?*YesNoAt what pace can the applicant do activities?*SlowAverageSometimes fastContinual 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: $50.00 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin 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.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.Parent/guardian signature*Type your full name. This will serve as your digital signature.CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
