Application Step 1 of 4 25% CHILD’S INFORMATIONTODAY DATE MM slash DD slash YYYY FULL NAME First UPLOAD A PICTUREMax. file size: 64 MB.DATE OF BIRTH MM slash DD slash YYYY GENDERHEIGHTWEIGHTAddress 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 MEDICAID NUMBERDOES YOUR CHILD HAVE PRIVATE INSURANCE? Yes No DOES YOUR CHILD RECEIVE GAPP SERVICES TODAY? Yes No DOES YOUR CHILD RECEIVE ANY OTHER SERVICES FROM A MEDICAID PROGRAM? Yes No DOES YOUR CHILD ATTEND SCHOOL? Yes No WHAT IS THE NAME OF THE SCHOOL?SELECT ALL DAYS YOUR CHILD ATTENDS SCHOOL Monday Tuesday Wednesday Thursday Friday WHAT HOURS DOES YOUR CHILD ATTEND SCHOOL EACH DAY?DOES YOUR CHILD HAVE A PERSONAL NURSE AT SCHOOL? Yes No DOES YOUR CHILD HAVE A CURRENT IEP? Yes No PARENT/FAMILY INFORMATIONMother's Full Name First PhoneMother Email Address Mother's Full Name First Father Phone NumberFather Email Address DOES YOUR CHILD LIVE WITH BOTH PARENTS? Yes No HOW MANY CHILDREN UNDER 17 YEARS OLD LIVE IN THE HOME?ARE THERE ANY OTHER MEDICALLY FRAGILE CHILDREN IN THE HOME? Yes No IS THERE ANYONE ELSE IN YOUR HOME WHO IS CURRENTLY IN THE GAPP PROGRAM? Yes No EMERGENCY CONTACTNAME First PHONE NUMBEREMAIL RELATIONSHIP TO CHILDNAME First PHONE NUMBEREMAIL RELATIONSHIP TO CHILDIS YOUR CHILD IN DEPARTMENT OF FAMILY AND CHILDREN SERVICES (DFCS) CUSTODY? Yes No CHILD’S MEDICAL INFORMATIONWHAT IS THE CHILD'S MEDICAL DIAGNOSIS? EX: CEREBRAL PALSY, DOWN SYNDROME, ETC. LIST ALLDOES YOUR CHILD HAVE ANY OF THE FOLLOWING EQUIPMENT? Wheelchair Gait Trainer Trach Catheter Shower Chair Walker G-Tube Standers Suction Leg Brace AAC Device Special Bed/ Safe Bed Glasses Oxygen Other LISTDOES YOUR CHILD HAVE VISION ISSUES? Yes No DOES YOUR CHILD HAVE HEARING ISSUES? Yes No DOES YOUR CHILD HAVE ANY OPEN WOUNDS? Yes No DOES YOUR CHILD WEAR DIAPERS OR PULLUPS? Yes No CAN YOUR CHILD USE THE BATHROOM WITHOUT ASSISTANCE? Yes No WHAT TYPE OF BATHING DOES YOUR CHILD TAKE? Showers Tub Bath Bed Bath IS YOUR CHILD A FALL RISK? Yes No DOES YOUR CHILD HAVE CONTRACTURES?A PERMANENT TIGHTENING OF THE MUSCLES, TENDONS, SKIN, AND NEARBY TISSUES THAT CAUSES THE JOINTS TO SHORTEN AND BECOME VERY STIFF. THIS PREVENTS NORMAL MOVEMENT OF A JOINT OR OTHER BODY PART. CONTRACTURES MAY BE CAUSED BY INJURY, SCARRING, AND NERVE DAMAGE, OR BY NOT USING THE MUSCLES. Yes No DOES YOUR CHILD WEAR AFO’S?ANKLE-FOOT ORTHOSES (AFOS) ARE LOWER LIMB ORTHOSES THAT ARE CUSTOM MADE FOR EACH INDIVIDUAL TO ENCOMPASS THE FOOT, ANKLE AND LEG, JUST FINISHING BELOW THE KNEE. Yes No DOES YOUR CHILD RECEIVE ANY OF THE FOLLOWING SERVICES? Occupational Therapy (OT) Physical Therapy (PT) Speech Therapy My Child Does Not Receive Any Of These Services HAS YOUR CHILD BEEN PRESCRIBED TO DO ANY OF THE FOLLOWING EXERCISES? ROM (Range of Motion) Light Massages Lower Back Stretches Standers None of the Above Pediatrician Contact Details:NAME OF PRACTICEDOCTOR'S NAMEADDRESSPHONE NUMBERList Physician’s Involved in your child’s careDOCTOR'S NAMESPECIALTYPHONE NUMBERList all of your child’s medications, ex: Keppra, 20ml, Once a Day, By Mouth, Dr. Smith:NAMEDOSAGEFREQUENCYINSTRUCTIONS, EX: BY MOUTH, G-TUBEPRESCRIBING PHYSICIANDOES YOUR CHILD HAVE SEIZURES? IF YOU HAVE A SEIZURE LOG, PLEASE EMAIL US. Yes No LIST ALL SURGERIES AND HOSPITALIZATIONS WITH DATESWhen was your child’s last appointment with his/her primary care physician listed above?DOES YOUR CHILD HAVE ANY ALLERGIES? Yes No DESCRIBE YOUR CHILD'S LIMITATION IN YOUR WORDSNUTRITIONAL REQUIREMENTSDOES YOUR CHILD HAVE A SPECIAL DIET? Yes No WHICH TYPE OF FEEDING DOES YOUR CHILD USE? Regular Feeding Bite-Sized Pureed G-Tube Liquid Diet DOES YOUR CHILD HAVE SWALLOWING ISSUES? Yes No HOW CAN WE HELP YOU?Listed below are tasks that our staff can assist you with when providing care for your child. Please check off the boxes below that show the tasks that our staff can work with your child on during his or her scheduled shift. We will then use this information to create your child's plan of care.BATHING Bed Bath Shower Bathtub Bathing AMBULATION (WALKING ASSISTANCE) Ambulation Assistance Monitor for Fall Prevention Range of Motion Exercise COMPANIONSHIP Assist with Hobbies Encourage Conversation and Mental Stimulation Provide Caregiver Relief Companion Sitter Services Laundry Assistance Reading Walk Outside Watch Television with Client HOUSEKEEPING Change Linen Clean and Put Away Dishes Clean and Put Away Laundry Clean Bathroom Clean Bedroom Clean Den/Living Room Clean Kitchen Cut Food Dusting Empty Dishwasher Light Housekeeping Make or Change Bed Mop Floor Sweep Floor TRANSFERRING Transfer Out of Bed/Chair - Hands on Assist Transfer Out of Bed/Chair - Standby Assistance Transfer Out of Bed/Chair - Verbal Cue or Reminder DIET Regular Diet Pureed Diet Liquid Diet Soft Diet PERSONAL CARE Assist with Medical Device Brush Hair Nail Care Brush Teeth Rotate/Reposition Comb Hair Shampoo Hair Dress/Grooming Eating Toileting Assistance Escort to Activities Apply Lotion to Skin TOILETING Assist With Getting On and Off Toilet Assist With Getting To and From Bathroom Safely Bedpan Assist Bowl Incontinence Assist Change Depends/Diapers/Briefs Toilet Wipe Down Catheter Care Assistance Toileting (Hands on Assistance) Toileting (Standby Assistance) Toileting (Verbal Reminders) NUTRITIONAL SERVICES Encourage to Drink Fluids Encourage Eating Feeding Assistance Prepare Meals Record Food Intake Record Liquid Intake MEDICATION SERVICES Assist with Insulin Administration G-Tube Med Administration Insulin Syringe Fill Medication Administration Medication Reminders Oxygen Care FEEDING Feeding - Assist via spoon Fed Feeding - Verbal Cue or Reminder G-Tube Feeding G-Tube Feeding with Flush Observe While Eating Open Packages SKILLED NURSING SERVICES Blood Pressure Check Catheter Care - Clean Around Site Catheter Care - Empty Bag CBG Check Pulse Check Change MIC-Key Button Change MIC-Key Balloon Fill Pill Box Respiration Check G-Tube Care - Cleaning Around Site Glucose Check INR Check Mikey Button Change Monitor Bipap/Ventiltor and Settings Monitor for Seizure Activity Monitor for Shunt Malfunction NG Tube Feedings NG Tube Insertion Ostomy Care - Change Bag Ostomy Care - Clean Around Site Pain Assessment Perform Neuro Checks Trach Care - Cleaning Around Site Trach Change Turning/Repositioning Weight Check Wound Care CHILD’S PICTURE HEREMax. file size: 64 MB.CHILD’S MEDICAID CARD HEREMax. file size: 64 MB.CHILD’S SOCIAL SECURITY CARDMax. file size: 64 MB.NameThis field is for validation purposes and should be left unchanged.
