Fillable Service Application - Progressive Community Network

Application for Services

Thank you for your interest in receiving services through Progressive Community Network!

As part of our referral process, we kindly request the following information (as applicable) to help us better understand the applicant’s needs:

Contact information for involved family or support team
Current social history
List of current medications and diagnoses
SIS Assessment or InterRAI
Individual Service Plan (ISP)
Incident reports from the past 6 months
Most recent psychiatric or psychological assessment

Please upload these documents along with your application to ensure a timely review.

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Today's Date: *

Applican't Full Name *

First

Middle

Last

Phone Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth: *

Gender: *

Primary Diagnosis: *

Is current placement in jeopardy? *

Placement needed by date: *

Has the applicant ever recieved services outside of the family home? *

If yes, current/most recent provider:

Phone number for current/most recent provider:

Does applicant have a guardian? *

Yes
No
Self

Guardian Name (If applicable):

First

Last

Guardian Relationship to applicant:

Guardian Phone Number:

Guardian Email (If applicable):

Case Manager/Care Coordinator: *

First

Last

Case Manager/Care Coordinator Phone Number: *

Case Manager/Care Coordinator Email: *

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Funding Source: *

Wellpoint
IME
Iowa Total Care
MHDS
Private Pay
Other

If other, please list:

Funging Type:

Please type in either: ID Waiver & Tier or Habilitation & Tier. *

Applicant's Financial Source: *

Social Security (SSA)
Supplemental Social Security (SSI)
Trust Fund
Veteran’s Benefits (VA)
Child Support Adoption Subsidy
Other Service(s)

If other service(s) please list:

Service Delivery Requested: *

Host Home: is a service where individuals live in private family homes and receive specialized assistance from a dedicated caregiver.
HCBS 24/7 SCL Homes: is a service where an individual would live in their own home with one to three roommates and have dedicated staff that work in shifts to provide support.

Health/Medical Information:

Please list any adaptive equipment used such as: Cane, Walker, Wheelchair (Manual), Wheelchair (Motorized), Other. Please list all equipment used.

Specialized Medical Needs:

Please list any needs such as: Blind, Deaf, Diabetic with insulin shots, Seizures, Dialysis, Feeding Tube, etc.

Referral History:

Does the applicant have a current court committal? *

Has the applicant ever been arrested? *

If yes, is the applicant:

Awaiting Charges
On Probation
On Parole
Other

If other, please explain:

Has the applicant been accused/convicted of sexual abuse? *

Is the applicant listed on any state or national sex offender registry? *

Does the applicant have a history of cruelty to animals? *

Does the applicant have a history of attempted suicide? *

Does the applicant have a history of fire setting? *

Does the applicant have a history of cutting, swallowing, and insertion of foreign objects or strangulation? *

Introduction:

The following questions are designed to help us better understand your needs and preferences. By sharing this information, you enable us to make thoughtful placement decisions that best support you or your loved one. Your responses will guide us in creating the most positive, safe, and supportive environment possible.

What area are you looking to live in? *

What type of Home would you prefer to live in? *

Is please Email

Please describe what an average day in your life looks like: *

What is your religious/faith base if any? *

What are your interests and hobbies? *

What does your “perfect” day look like? *

What would you like a potential Host Home Provider to know about you? *

The information we have asked you to provide is necessary for the effective administration of the services for which you are applying. The information collected will only be used by authorized agency personnel. Use of this information for purposes other than expressed herein will not occur without your prior written approval, unless such other use is specified.

Application completed by:

Name *

First

Last

Relationship to applicant: *

Please upload the following information if you have them available:

Current social history
List of current medications & diagnoses
SIS assessment/InterRAI
Individual Service Plan (ISP)
Incident reports from prior 6 months
Psychiatric/psychological assessment
Contact information for involved family/support

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Max File Upload 512 MG

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Email *

Application for Services

Introduction:

Please upload the following information if you have them available:

Max File Upload 512 MG

Business Hours:

Menu:

Get in touch
with us today!

Application for Services

Introduction:

Please upload the following information if you have them available:

Max File Upload 512 MG

Business Hours:

Menu:

Get in touch with us today!

Get in touch
with us today!