Fillable Service Application - Progressive Community Network

Application For Services

Thank you for your interest in services with Progressive Community Network. We request the following information (as applicable) as part of our referral process to assist us in determining the service needs of the applicant:

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

Please upload the above information with your application.

If the files are too large please e-mail them to: info@progressivecommunitynetwork.com

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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: *

Funding Source: *

Wellpoint
IME
Iowa Total Care
MHDS
Private Pay
N/A

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? *

applicable): (If list

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? *

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

File Upload

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Max File Upload 512 MG

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