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Diagnosis Action
First Name Last Name Action

Disability Information

Contact Person
Phone Number
Date of onset of disability
How would you describe your general health?

Living Information

If you had a choice, where would you choose to live? Is there a specific person(s) you would like to live with, or would you choose to live alone? Please explain.
What is your present living arrangement? Check one of the following:


The ICWP does not allow members to live in Personal Care Homes. Would you be willing to move into an Alternative Living Services (ALS) Home?
Nursing Home/ALS/ PCH Name
Address
Phone number
Social Worker
Mobile number
Email
Date admitted
Date discharged

If application is being submitted by MFP

Does the facility have internet capability?
Does the facility have access to a device with a web cam?
Is the applicant currently receiving
Please submit

ICWP assessors have the ability to conduct the assessment via internet.

Do you live in a home that has internet access and a device with web cam (laptop, computer, tablet, etc.)?
Would you be interested in conducting the assessment by videoconference?
If so, please provide a valid email address:

Please check one item that BEST describes how you transfer

ACTIVITIES OF DAILY LIVING NEEDS

Please indicate, in each row, how much assistance you need
Total Partial Minimal None

EQUIPMENT YOU USE DAILY

Use Needed/Requested

Do you require any of the following interventions?

RELATIONSHIPS

Do you have regular visitors?
Who visits? (Check ALL that apply)(Frequency)

Help needed at the following times (Check all that apply)

Time Hour

Please identify caregivers who will commit to providing care on a daily basis.

Add more caregiver

List all the medications you are currently taking

Name of Medication Dose strength How is it given? Oral / Inhaler/ Injection How often is it given?
Add more

List your current doctors you routinely see

Doctor's name Specialty City / Location When did you last see the doctor?
Add more doctor
How many times have you needed hospital care in the past year?
Diagnosis for your hospital admission? How long were you there? Approximate dates?
Add more diagnosis
Are you currently receiving services from another wavier program?
If so, from which program do you receive services?
How many hours per day or per week do you receive?
Do these services sufficiently meet your needs?
Why or Why not?
Please provide any additional information that would be helpful in identifying your needs.