Application for Services — Uni-Hope Life Skills & Services, LLC

Admissions Standards

Once your application has been completed and submitted along with supporting documentation, you will be contacted for an intake interview. The Admissions Director will review your application within 7 business days and issue a written decision. Upon acceptance, you will be assigned a service coordinator who will coordinate service needs and provide a start date.

939 Office Park Rd. Suite 201, West Des Moines, Iowa 50265

Supporting Documents Checklist

Please check each document you are including with this application. Incomplete applications will be returned for completion.

Signed Release of Information — Authorization Case Management Plan / Service Plan (including psychological and SIS Assessment) General medical / physical examination (completed within the last 12 months) Guardianship documents (if applicable) Social History Medical History (report from primary healthcare provider on physical and mental status, medications) Behavior Support Plans / Crisis Management Plan (if applicable)

General Information

Applicant

Date

Applicant Legal Name

Preferred Name

Applicant Address

City

State

Zip Code

Primary Phone

Secondary Phone

Email Address

Guardian Information (if applicable)

Guardian Name

Relationship to Applicant

Guardian Address

City

State

Zip Code

Primary Phone

Secondary Phone

Guardian Email

Services Requested

Other Services Requested (not listed above)

Current Medications

Applicant must be approved to receive services under: Brain Injury, Elderly, Health and Disability, Intellectual Disability, or Habitation waivers. All applicants must be above the age of 18.

Financial Information

Current Benefits — Monthly Amounts

SSI

SSDI

Food Stamps / SNAP

TANF

Housing Assistance (incl. Section 8)

Veteran Benefits

Workers Compensation

Other Benefits

Were any benefits terminated within 2 years of this application date?

Yes

Education & Skills

Education

School Attended

Location

Highest Level of Education

Did you participate in special education programming?

Yes

Skills & Interests

Life Skills

Strengths

Areas of Need

Leisure Time / Enjoyment

Other Notes

Referral Information

Referral Source / Case Manager

Company / Organization

Address

City

State

Zip Code

Phone

Medicaid MCO & Funding Source

Medicaid MCO — Select all that apply

Amerigroup Iowa

Total Care

Molina HealthCare

Polk County Funding

Private Funding Source

List of Agencies / Individuals to Receive Your Report

Other Interested Parties You Permit Involvement

Name of Individual Completing This Form

Acknowledgement & Authorization to Release Information

Acknowledgement

Uni-Hope Life Skills and Services, LLC requires that the Applicant has actual knowledge for this referral before it will be considered by the Admissions Committee.

I confirm that I have actual knowledge of this referral and agree that it may be considered by the Admissions Committee.

Applicant Signature *

Date

Co-Guardian Signatures (if applicable)

Co-Guardian Signature 1

Co-Guardian Name (Printed)

Date

Co-Guardian Signature 2

Co-Guardian Name (Printed)

Date

Authorization to Release / Receive Confidential Information

I hereby give permission to Uni-Hope Life Skills and Services, LLC ("Uni-Hope") to release information, including information contained in my Application for Services as well as supporting documentation, to the Uni-Hope Admissions Committee in order to determine eligibility and provide recommendations for services provided by Uni-Hope.

I understand the information will be reviewed and analyzed in assessing the services that Uni-Hope can provide to me. I understand that this release is valid for one year from the date below, unless I contact Uni-Hope in writing revoking the authorization. I understand that in order to revoke this authorization, I must provide Uni-Hope written notice revoking this release.

I authorize Uni-Hope Life Skills and Services, LLC to release my information as described above to the Admissions Committee.

Applicant Signature — Authorization *

Date

Co-Guardian Signature 1 — Authorization

Co-Guardian Name (Printed)

Date

Co-Guardian Signature 2 — Authorization

Co-Guardian Name (Printed)

Date

Securely submitted • Data encrypted in transit

Waiver / Category	SCL / Daily	SCL / Hourly	Host Home
Intellectual Disability
Habilitation
Brain Injury