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Application for Services
Applicant Info
Applicant Name
Date Of Birth
Guardian Info
Guardian Name
Relationship
Main Phone
Secondary Phone
Current Address
Street Address
Apt., Suite, other #
City
State
Zip
Address Other (if less than 5 years at current)
Street Address
Apt., Suite, other #
City
State
Zip
Primary Email
Emergency Contact (if guardian cannot be reached)
Name
Phone
Financial Info
Please be as specific as possible with the financial information since some services are income/asset based
Social Security
Social Security #
Social Security Amount
Medicaid
Medicaid #
Medicaid Amount
Medicare
Medicare #
Medicare Part
Part A
Part B
Part C
Innovation Waver
Innovation Waver Services
Yes
No
Services
State Funding
State Funding
Yes
No
Services
Other Sources (SSI/SSA/etc)
Other Sources (SSI/SSA/etc)
Amount
Life Insurance
Life Insurance Policy
Amount
Living Will
Burial Plan Policy
Savings Account
Financial Institution
Amount
Trust Fund
Trust Fund
Amount
Property
Other assets or income
401K or 403B account
401K or 403B account
Amount
HVO or other day/work schedule
Currently enrolled with Vaya Health
Yes
No
Vaya Health Record #
Why does the individual want/need group home placement?
Diagnosis
Special Needs/Accommodations/Health Care Concerns
List all Medical Providers #1
Provider Name
Phone
Street Address
Apt., Suite, other #
City
State
Zip
List all Medical Providers #2
Provider Name
Phone
Street Address
Apt., Suite, other #
City
State
Zip
List all Medical Providers #3
Provider Name
Phone
Street Address
Apt., Suite, other #
City
State
Zip
List all Medications and dosage
Medication / Dosage
List Previous Group Home/AFL Placements
Name
Phone
Street Address
Apt., Suite, other #
City
State
Zip
List Any Additional Previous Group Home/AFL Placements Here
Attachments
Copy of legal guardianship documents
Psychological Evaluation
Send Application
