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1 DATE OF INTAKE: Page 1 STAFF NAME: FIRST NAME: MIDDLE INITIAL: STREET ADDRESS: LAST NAME: CITY: STATE: ZIP: HOME PHONE: MOBILE: OTHER: BIRTH DATE: GENDER: SOC. SEC. NO. SPECIAL CONSIDERATION: Male Female VETERAN Yes No (Specify special consideration for communication) ETHNICITY African American Native American/Alaska Native Asian Native Hawaiian or Pacific Islander White/Caucasian Hispanic/Latino Other Not given LAGUAGE FOR WRITTEN MATERIAL English Spanish Both Other CLIENT ELIGIBILITY VERIFICATION Significant Disability/Sensory Impairment have been verified: Yes No Functional limitation(s) to independence has been verified: Yes No There is adequate indication that the client will benefit from participation in services Yes No How client eligibility was determined: (Check all that apply) OBSERVATION SELF-DISCLOSURE SSI/DI STUB/MASS HEALTH OTHER Client is eligible for services: STAFF SIGNATURE DATE Client is NOT eligible for services
2 Page 2 DISABILITY PRI ALL PRI ALL ALS Amputation Arthritis Autism/Asperger s Syndrome Blindness C.P. Cancer Chemical Dependency Chronic Fatigue Syndrome COPD Deaf Degenerative Disease Diabetes Down Syndrome Dyscalculia Dysgraphia Dyslexia Environmental Sensitivity Epilepsy Fibromyalgia Friedrich s Ataxia Hard of Hearing Heart Disease HIV/AIDS Late Deafness LD/ADD/ADHD Lupus M.D. M.R/Developmental M.S. Oral Deafness Orthopedic Other - Cognitive Other - Neurological Other - Physical Other - Sensory Parkinson s Disease Polio SCI Speech Impairment Spina Bifida Stroke TBI Cognitive Visual Impairment Other not listed above Date of onset of primary disability REASON FOR SEEKING SERVICES Please check all that apply Communication Assist. CA EM Employment SH Self-help/Personal Growth CL Consumer/Legal Rights ME Employment Maintenance OT Other ET Education/Training SPECIFIC SITUATION OR NEED: (Detailed reason for seeking services)
3 EDUCATION Page 3 EMPLOYMENT EMPLOYED If yes, please give information below: 6th Grade and below 9th Grade 11th Grade High School Special Education Some College Associate Degree Bachelor s Degree Trade School Graduate School INCOME Source SSDI SS Retirement SSI Unemployment Compensation EAEDC Employment Other Amount Frequency (Weekly, Bi-weekly, Monthly, Annual Amount Frequency (Weekly, Bi-weekly, Monthly, Annual NON-CASH BENEFITS Source Food Stamps Fuel Assistance Other COMMUNICATION AIDS/METHODS Communication Board TTY/TDD/Telebrailler Hearing Aids Assistive Listening Device Interpreter Computer-Assisted Communication Hearing Dog TRANSPORTATION Own Transportation Driver Own Transportation Drives self Para-transit Public Transportation w/o Assistance Public Transportation with Assistance Drive by others, their vehicles
4 Page 4 EMERGENCY CONTACT In case of emergency, contact First Name Street Address Middle Initial City Phone State Last Name Zip Code Mobile Relationship PHYSICIAN Primary Physician: First Name Street Address Middle Initial City Phone State Last Name Zip Code TTY/TDD Other: First Name Street Address Phone Middle Initial City State Last Name Zip Code TTY/TDD
5 Page 5 OTHER COMMENTS OTHER ASSOCIATED PEOPLE NAME: ADDRESS: PHONE/MOBILE: RELATIONSHIP: NAME: ADDRESS: PHONE/MOBILE: RELATIONSHIP: NAME: ADDRESS: PHONE/MOBILE: RELATIONSHIP: NAME: ADDRESS: PHONE/MOBILE: RELATIONSHIP:
6 AUTHORIZATION FOR RELEASE OF INFORMATION Client s Name: Address: Street Address City State Zip Code I hereby authorize Asperger Works, Inc. (AWorks) to release and receive my individually identifiable medical or personal information for the strict purpose of assisting me in the achievement of the Goals as stated in my Asperger Works Service Plan (AWSP), or as authorized in other written or verbal documented communication with Asperger Works, Inc. staff members. Client of Legal Guardian Signature: Date: I authorize AWorks to release my information to any individual or agency as appropriate. This release of information is valid for the duration of my time as an active client with Asperger Works, Inc. unless otherwise voided by a written request. If you wish to have AWorks share information ONLY with a specific individual or agency, please check the appropriate box below: Social Security Administration MCDHH NILP Hospital Staff Home Health Care Agency MRC DMH Health Insurance Provider Medical Professional Individual PCA Other 60 Island Street, Suite 208E Lawrence, MA Visit us on the Web at
7 ****************************************************************************** NOTICE OF PRIVACY PRACTICES ****************************************************************************** This notice describes how health and/or employment information about you may be used and disclosed and how you can get access to this information. Please review it carefully. The privacy of your health insurance is important to us. OUR LEGAL DUTY We are required by applicable Federal and State law to maintain the privacy of your health information. We are also required to give you the Notice about our privacy practices, our legal duties, and your right concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 1/01/17 and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make any significant change in our privacy practices, we will change this Notice and make the new Notice available upon request. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice. 60 Island Street, Suite 208E Lawrence, MA Visit us on the Web at cs@aspergerworks.org us us at at infor@aspergerworks.org
8 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES ******************************************************************* *You may refuse to sign this acknowledgement* I, Asperger Works Notice of Privacy Practices., have received a copy of Please print your name Signature Date FOR OFFICE USE ONLY We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communication barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please specify): 60 Island Street, Suite 208E Lawrence, MA Visit us on the Web at us at cs@aspergerworks.org info@aspergerworks.org
9 Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, domestic violence, or the possible victim of other crimes. We may disclose you health information to the extent necessary to avert serious threat to your health or safety or the health or safety of others. National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized Federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution of law enforcement officials having lawful custody of protected health information of inmate or client under certain circumstances. Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voic messages, postcards, s, or letters). CLIENT RIGHTS Access: You have the right to look at or get copies of your health information with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information by using the contact information listed at the end of this Notice. Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means. 60 Island Street, Suite 208E Lawrence, MA Visit us on the Web at cs@aspergerworks.org us at info@aspergerworks.org
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