Crossing All Bridges Learning Centre
Intake Application Form
Please answer all questions. All information is confidential and for the use of
Crossing All Bridges Learning Centre. Successful applicants must be diagnosed with a
developmental disability and be over the age of 18. The individual must be able to independently
toilet themselves, feed themselves and manage interaction and socialization in group settings.
APPLICANT INFORMATION (Applicant is the person for whom service is required)
FIRST NAME ________________________ LAST NAME __________________________
MIDDLE INITIAL ____________________ NAME USED ___________________________
DATE OF BIRTH _____________________ GENDER
MALE []
FEMALE []
ADDRESS___________________________________________________________________________
__________________________________________POSTAL CODE ______________
PHONE # DAY ______________________EVENING___________________________
CELL PHONE________________________________
EMAIL ADDRESS_____________________________
PARENT/PRIMARY CAREGIVER INFORMARTION (person completing the form)
FIRST NAME ________________________ LAST NAME __________________________
RELATIONSHIP TO APPLICANT __________________________
ADDRESS
SAME AS APPLICANT [] if not, list below
ADDRESS___________________________________________________________________________
__________________________________________POSTAL CODE ______________
PHONE # DAY ______________________EVENING___________________________
CELL PHONE______________________BUSINESS_______________________ EXT___
EMAIL ADDRESS_____________________________
MEDICAL CONTACT
FAMILY DOCTORS NAME __________________________
ADDRESS_______________________________________ PHONE ___________________________
ARE ALL OF YOUR IMMUNIZATIONS UP TO DATE? __________________________________
IF NOT, PLEASE SPECIFY ___________________________________________________________
PRESENT LIVING SITUATION
[] PARENTAL HOME
[] GROUP HOME [] OTHER (please specify) _________________
RESPITE
USES RESPITE SERVICES [] YES NO [] IF YES, PLEASE LIST THE AGENCY’S NAME AND
ADDRESS___________________________________________________________________________
PHONE NUMBER___________________________ HOW MANY DAYS IN A MONTH ARE SPENT
AT RESPITE _________________ DOES ATTENDING RESPITE CAUSE BEHAIOURAL
N/Drive, Registration 2015-2016, Crossing All Bridges Learning Centre Intake Application Form
CHANGES (anxiety, frustration) [] YES [] NO
IF YES, PLEASE LIST BEHAVIOURS
_____________________________________________________________________________________
DIAGNOSIS INFORMATION (check all that apply)
[] NONE []AUTISM []BLINDNESS []BRAIN OR NEUROLOGICAL DAMAGE
[]CEREBRAL PALSY []DEAFNESS []DOWNSYNDROM []DEVELOPMENTAL DISABILITY
[]EPILEPSY OR SEIZURES []HEART CONDITION [] PACE MAKER []IMPULSE CONTROL
[]ANXIETY []DEPRESSION []OBSESSIVE COMPULSIVE DISORDER []SELF HARMING
BEHAVIOURS []SLEEP APNEA [] RESPIRATORY NEEDS [] CIRCULATROY OR CARDIAC
NEEDS [] FETAL ALCOHOL SYNDROME [] PRODER-WILLI []IMPLANTS/ARTIFICAL JOINT
[] RANGE OF MOTION ISSUES
[] PHYSICAL DISABILITY (please specify)_________________________________________
[] SITUATIONAL MENTAL HEALTH PROBLEM (formal diagnosis) depression, anxiety, mood
disturbance|______________________________________________________________________
ALLERGIES
PLEASE LIST CLEARLY ____________________________________________________
FOOD _______________________________DRUGS _________________________________
ENVIRONMENTAL (latex, dust, bee stings) __________________________
WHAT PHYSICAL SIGNS INDICATE AN ALLERGIC
REACTION?____________________________________________________________________
DIFFICULTIES CHEWING______________________ ITEMS ___________________________
NUTRITION
Are there any special dietary requirements? ________________________________
MEDICAL HISTORY please give a brief description of the applicants condition and signs or symptoms
to be aware of
_______________________________________________________________________________
________________________________________________________________________________
CURRENT MEDICATIONS
[] NONE [] FOR HEALTH PROBLEMS [] FOR EPILEPSY/SEIZURES [] MOOD [] ANXIETY
[] SLEEP [] BEHAVIOUR []
Please list all current medications_____________________________________________________
IS AN EPIPEN REQUIRED [] YES
[] NO
LEVEL OF DEVELOPMENTAL DISABILITY (select one)
[] INDEPENDENT [] REQUIRES PROMPTS/REMINDERS [] REQUIRES ASSISTANCE
[] DEPENDENT
MOBILITY
[] WALKS WITHOUT AIDS [] WALKS WITH AIDS SUCH AS CRUTHCES, WALKER
[] USUALLY IN WHEELCHAIR OR DOES NOT WALK
N/Drive, Registration 2015-2016, Crossing All Bridges Learning Centre Intake Application Form
PAST DAY ACTIVITIES
[] DAY PROGRAM – NAME OF AGENCY ____________________________________
[] SCHOOL- NAME OF SCHOOL ____________________________________________
SCHOOL CONTACT PERSON ___________________________________
OTHER ______________________________________________________
DOES THE INDIVIDUAL CURRENTLY VOLUNTEER [] YES [] NO IF SO, PLEASE LIST
WHERE ___________________________________________
IS THE INDIVIDUAL EMPLOYED [] YES [] NO
IF YES, PLEASE LIST EMPLOYER
_____________________________________ HOW MANY HOURS ______________________
Please note: applicants are required to sign a consent to release form to allow Crossing All Bridges
Learning Centre to obtain information from current and past agencies who have provided or are providing
service. This information is necessary in order for Crossing All Bridges Learning Centre to assess needs
and confirm eligibility to receive services from Crossing |All Bridges Learning Centre.
LITERACY SKILLS (select all applicable)
ABLE TO READ
[] YES
CAN IDENTIFY NUMBERS
[] YES
CAN IDENTIFY LETTERS
[] YES
UNDERSTANDS MONEY
[] YES
CAN WRITE OWN NAME
[] YES
CAN WRITE WORDS
[] YES
USES BRAILLE
[] YES
READS FOR PLEASURE
[] YES
CAN WRITE TO COMMUNICATE [] YES
[] NO
[] NO
[] NO
[] NO
[] NO
[] NO
[] NO
[] NO
[] NO
COMMUNICATION
UNDERSTANDS COMPLEX INSTRUCTIONS
[] YES
UNDERSTANDS SIMPLE INSTRUCTIONS
[] YES
UNDERSTANDS IF SHOWN
[] YES
USES PEC BOARD
[] YES
HAS PREVIOUSLY USED PEC BOARD
[] YES
USES SIGN LANGUAGE TO COMMUNICATE
[] YES
HAS SOME KNOWLEDGE OF SIGN LANGUAGE [] YES
CAN VERBALLY COMMUNICATE
[] YES
CAN RESPOND TO QUESTIONS
[] YES
CAN ENGAGE IN CONVERSATION
[] YES
[] NO
[] NO
[] NO
[] NO
[] NO
[] NO
[] NO
[] NO
[] NO
[] NO
INDEPENDENCE (select all applicable)
COMPLETELY INDEPENDENT
CAN BE LEFT ALONE FOR SHORT PERIODS
OF TIME
REQUIRES PROMPT/REMINDERS
REQUIRES CONSTANT SUPERVISION
DOES WANDER
ABLE TO FOLLOW VERBAL INSTRUCIONS
NEEDS HAND OVER HAND ASSISTANCE
FOR MANUAL TASK
[] YES
[] YES
[] NO
[] NO
[] YES
[] YES
[] YES
[] YES
[] NO
[] NO
[] NO
[] NO
[] YES
[] NO
N/Drive, Registration 2015-2016, Crossing All Bridges Learning Centre Intake Application Form
PERSONAL CARE
IS ABLE TO TOILET INDEPENDENTLY
NEEDS ASSISTANCE WITH PERSONAL CARE
TOILETING
ABLE TO WASH HANDS
ABLE TO FEED THEMSELVES
ABLE TO DRESS THEMSELVES
NEEDS ASSISTANCE WITH SHOE TIEING
BOOTS OR OUTERWEAR
[] YES
[] NO
[] YES
[] YES
[] YES
[] YES
[] NO
[] NO
[] NO
[] NO
[] YES
[] NO
BEHAVIOURAL CHALLENGES
Has there been any police involvement in the past? [] yes [] no
If yes, please describe
_____________________________________________________________________________________
_____________________________________________________
DOES YOUR INDIVIDUAL EXIBIT ANY OF THE FOLLOWING BEHAVIOURS, please check
the box applicable box and indicate how these challenges can be successfully handled
1- NEVER
2- RARELY
3- SOMETIMES
4- OFTEN
PHYSICAL AGGRESSION
[]1 []2 []3 []4
_____________________________________________________________________________________
_____________________________________________________________________________________
FRUSTURATION
[]1 []2 []3 []4
_____________________________________________________________________________________
_____________________________________________________________________________________
OUTBURSTS
[]1 []2 []3 []4
_____________________________________________________________________________________
_____________________________________________________________________________________
TEMPER TANTRUM
[]1 []2 []3 []4
_____________________________________________________________________________________
_____________________________________________________________________________________
STUBBORN
[]1 []2 []3 []4
_____________________________________________________________________________________
_____________________________________________________________________________________
EXTREME SHYNESS
[]1 []2 []3 []4
_____________________________________________________________________________________
_____________________________________________________________________________________
N/Drive, Registration 2015-2016, Crossing All Bridges Learning Centre Intake Application Form
SELF HARM
[]1 []2 []3 []4
_____________________________________________________________________________________
_____________________________________________________________________________________
OTHER
[]1 []2 []3 []4
_____________________________________________________________________________________
_____________________________________________________________________________________
PERSONAL INTERESTES (please check all that apply)
[] COOKING [] BAKING [] CRAFTS [] READING [] COLOURING [] ART
[] MOVIES/VIDEOS [] DANCING [] SINGING [] COMPUTER/INTERNET [] IPADS
[] SOCIALIZING [] ANIMALS [] DRAMA [] HIKING [] PHOTOGRAPHY [] MUSICAL
INSTRUMENTS
COMMENTS (additional comments which may be helpful to staff)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
DAYS OF THE WEEK REQUIRED
[] MONDAY TO FRIDAY
[] MONDAY [] TUESDAY [] WEDNESDAY
[] THURSDAY [] FRIDAY
LIST YOUR CHOICE OF DAYS IN ORDER OF YOUR PREFERENCE.
1. _____________ 2. _____________ 3. _____________ 4. ________________ 5. ______________
SIGNATURE (PERSON COMPLETING FORM)
_____________________________________________
PRINT NAME __________________________________ DATE______________________________
N/Drive, Registration 2015-2016, Crossing All Bridges Learning Centre Intake Application Form
N/Drive, Registration 2015-2016, Crossing All Bridges Learning Centre Intake Application Form