Application for Admission

Applicant's Information
Your Child's Name * Required
Preferred Name * Required
Sex * Required
- Male
- Female
Birthdate - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY
Place of Birth * Required
Parent/Guardian's Name * Required
Address * Required
Street Address Address Line 2 City State ZIP Code
Home Phone * Required
Work Phone * Required
Other Phone
E-Mail Address * Required
Does your child live with their parents? * Required
- Yes
- No
Where does your child live? * Required
Is your child currently hospitalized or in a residential facility? * Required
- Yes
- No
Where is your child hospitalized or residing? * Required
Please give address, phone #, and projected date of discharge.
Diagnosis * Required
At what age was your child diagnosed? * Required
Financial Sources * Required
- PASSE
- Medicaid
- SSI
- Social Security
- VA
- Private Insurance
- Tefra
- Child Support
- Trust Account
- Other
Check all that apply
Please describe other financial source: * Required
Guardian's Information
Guardian's Name * Required
Guardian's Birthdate - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY
Guardian’s Address * Required
Street Address Address Line 2 City State ZIP Code
Guardian's Home Phone * Required
Guardian's Work Phone * Required
Guardian's Employer * Required
Guardian's Employer's Address * Required
Guardian's Occupation * Required
Guardian's Work Days/Hours * Required
Guardian's Marital Status * Required
- Single
- Married
- Divorced
- Separated
- Widowed
Emergency Contact
Emergency Contact's Name * Required
Relationship to your child * Required
Emergency Contact's Phone * Required
Emergency Contact's Address * Required
Street Address Address Line 2 City State ZIP Code
Other Family

List all siblings:

Name	Age	Full/Half Sibling

List everyone who lives in the home with your child:

Name	Age	Relationship	Occupation

Are there other relatives not in the home who show interest in your child? (Grandparents, uncles, aunts, step-parents, brothers, sisters, etc.)

Name	Relationship	Address	Phone

General Questions
Why is application being made at this time? * Required
What are your expectations if your child is admitted to PCCA? * Required
What are your long range goals for your child? * Required
Has your child ever been placed in a foster home or other residential facility? * Required
- Yes
- No
If yes, please give locations and dates: * Required
Medical Information
Name of Primary Care Physician * Required
Primary Care Physician Phone * Required
Primary Care Physician Address * Required
Street Address Address Line 2 City State ZIP Code

Please list any social agencies, clinics, physicians, dentists, psychologists, therapists with which your child has had contact

Name/Agency	Address	City/State	PH.#	Dates Seen

Pregnancy History of Mother
Was mother under a physician's care during pregnancy? * Required
- Yes
- No
Was a physician present during delivery? * Required
- Yes
- No
Birth Weight * Required
Duration of Pregnancy * Required

(Weeks/Months)
Were there any illnesses, infections, unusual symptoms, or problems during pregnancy?
Were there any problems during labor? * Required
- Yes
- No
If yes, please explain: * Required
How long was your baby hospitalized at birth? * Required
Name of Hospital * Required
Address of Hospital * Required
Child's Medical History
Has your child ever had any of the following?
- Mumps
- Measles
- Chicken Pox
- Meningitis
- Pneumonia
- Bronchitis
- Flu vaccine
Is your child current on all vaccinations? * Required
- Yes
- No
Please list current medications: * Required
Is your child allergic to any foods or medications? * Required
- Yes
- No
If yes, please list allergies: * Required

Please list surgeries and hospitalizations:

Date	Diagnosis/Surgeries	Hospital

When did your child last have an Eye Exam?
Date Where/Who Results
When did your child last have a Hearing Evaluation?
Date Where/Who Results
When did your child last have a Dental Exam?
Date Where/Who Results
When did your child last have a Swallow Study?
Date Where/Who Results
When did your child last have a Psych Evaluation?
Date Where/Who Results
Therapy and Educational Information

Describe any of the following services your child is receiving or has received in the past: (include where, when, and frequency)
Physical Therapy
Occupational Therapy
Speech/Language Therapy
Has your child attended a Kids First program, Public School Special Education, or Day Treatment School? (if so, please tell when and where)
Please give names and addresses of any programs in which your child is currently enrolled:
Please attach the most recent Psychological evaluation report and IEP with this application, if you have it.
Max. file size: 256 MB.
Does your child use any of the following special equipment?
- Wheelchair
- Stander
- Walker
- Car seat
- Hand splints
- AFO’s
- Back brace
- Hearing aide
- Eye glasses
- Lap tray
- Augmentative communication device
- Other
Please describe other special equipment: * Required
Does your child roll? * Required
- Yes
- No
- With Assistance
Does your child crawl? * Required
- Yes
- No
- With Assistance
Does your child stand? * Required
- Yes
- No
- With Assistance
Does your child pivot transfer? * Required
- Yes
- No
- With Assistance
Does your child walk? * Required
- Yes
- No
- With Assistance
Does your child propel wheelchair? * Required
- Yes
- No
- With Assistance
What are your child's skills in bathing? * Required
- Independent
- Needs Assistance
- Totally dependent
What are your child's skills in dressing? * Required
- Independent
- Needs Assistance
- Totally dependent
What are your child's skills in toothbrushing? * Required
- Independent
- Needs Assistance
- Totally dependent
What are your child's skills in hair care? * Required
- Independent
- Needs Assistance
- Totally dependent
What are your child's skills in feeding? * Required
- Independent
- Needs Assistance
- Totally dependent
Does your child have challenges with sucking? * Required
- Yes
- No
If your child has challenges with sucking, please explain: * Required
Does your child have challenges with swallowing? * Required
- Yes
- No
If your child has challenges with swallowing, please explain: * Required
Does your child have challenges with chewing? * Required
- Yes
- No
If your child has challenges with chewing, please explain: * Required
Does your child have challenges with gagging? * Required
- Yes
- No
If your child has challenges with gagging, please explain: * Required
Does your child have challenges with biting? * Required
- Yes
- No
If your child has challenges with biting, please explain: * Required
Does your child have challenges with lip closure? * Required
- Yes
- No
If your child has challenges with lip closure, please explain: * Required
Does your child have challenges with drinking? * Required
- Yes
- No
If your child has challenges with drinking, please explain: * Required
Describe your child's diet: * Required
- Tube fed
- Bottle Fed
- Oral eater
- Strained baby food
- Pureed/Blended
- Mashed
- Finely chopped
- Coarsely chopped
- Regular, cut into small pieces
- Thickened liquids
- Must be fed by caregiver
- Feeds self using spoon
- Feeds self using spoon and fork
- Feeds self using fingers
- Drinks from a cup
Check all that apply.
How is your child positioned during meals? * Required
- Regular table/chair
- Wheelchair/table
- Highchair
- Booster chair/table
- Wheelchair/tray
- Feeder chair
- Held in feeder's lap
Does your child drink formula? * Required
- Yes
- No
If your child drinks formula, please list what kind(s): * Required
List your child’s favorite foods/flavors: * Required
List any foods/flavors your child dislikes: * Required
Behaviors

What does the applicant do when he/she is:
Happy * Required
Angry * Required
Scared * Required
Sick * Required
Hungry * Required
Wet/Soiled * Required
With other children * Required
Briefly describe your child's bedroom and other rooms in the home. * Required
(This helps us remind your child of his/her home and compare our environment to that which is familiar to your child)
Describe how your child sleeps. * Required
(With light or radio on? With stuffed animals? What size bed?)
Describe activities that your child enjoys: * Required
(Including outside activities like strolling, swinging, etc.)
Your child's daily routine: * Required
(Give approximate time of day)
What do you do when your child misbehaves? How do you discipline your child? * Required
What do you do to calm your child when he/she becomes upset? * Required
What family activities does your child enjoy the most? * Required
What is your child's least favorite activity? * Required
How does your child demonstrate dislikes? * Required
List favorite toys or objects and briefly describe: * Required
Please provide any other important information regarding your child which would be helpful to our staff * Required
Name of person completing application form * Required
Confirmation * Required
- I believe that the above information is correct to the best of my knowledge.
Parent/Guardian Signature

Please type your full name here to e-sign this form.
Authorization for Release of Information
Client * Required
Birthdate - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY
I, the parent/guardian of the above named client, hereby authorize Pediatric Complex Care of Arkansas to obtain from any source, any medical or personal information deemed necessary for the care of this client. This is to include written and/or verbal communication in person and over the telephone. I also authorize Pediatric Complex Care of Arkansas to release any medical or personal information to any facility or agency they deem appropriate.
First Name * Required
Last Name * Required
Today's Date: - must be mm/dd/yyyy format
MM slash DD slash YYYY
CAPTCHA

Applicant's Information

Guardian's Information

Emergency Contact

Other Family

General Questions

Medical Information

Pregnancy History of Mother

Child's Medical History

Therapy and Educational Information

Behaviors

Authorization for Release of Information