Application for Admission - Pediatric Complex Care of Arkansas

Applicant's Information

Your Child's Name *

Preferred Name *

Sex *

Male
Female

Birthdate *

Place of Birth *

Parent/Guardian's Name *

Address *

Street Address Address Line 2 City State ZIP Code

Home Phone *

Work Phone *

Other Phone

Does your child live with their parents? *

Yes
No

Where does your child live? *

Is your child currently hospitalized or in a residential facility? *

Yes
No

Where is your child hospitalized or residing? *

Please give address, phone #, and projected date of discharge.

Diagnosis *

At what age was your child diagnosed? *

Please describe other financial source: *

Guardian's Information

Guardian's Name *

Guardian's Birthdate *

Guardian’s Address *

Street Address Address Line 2 City State ZIP Code

Guardian's Home Phone *

Guardian's Work Phone *

Guardian's Employer *

Guardian's Employer's Address *

Guardian's Occupation *

Guardian's Work Days/Hours *

Emergency Contact

Emergency Contact's Name *

Relationship to your child *

Emergency Contact's Phone *

Emergency Contact's Address *

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? *

What are your expectations if your child is admitted to PCCA? *

What are your long range goals for your child? *

Has your child ever been placed in a foster home or other residential facility? *

Yes
No

If yes, please give locations and dates: *

Medical Information

Name of Primary Care Physician *

Primary Care Physician Phone *

Primary Care Physician Address *

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? *

Yes
No

Was a physician present during delivery? *

Yes
No

Birth Weight *

Duration of Pregnancy *

(Weeks/Months)

Were there any illnesses, infections, unusual symptoms, or problems during pregnancy?

Were there any problems during labor? *

Yes
No

If yes, please explain: *

How long was your baby hospitalized at birth? *

Name of Hospital *

Address of Hospital *

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? *

Yes
No

Please list current medications: *

Is your child allergic to any foods or medications? *

Yes
No

If yes, please list allergies: *

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.

Please describe other special equipment: *

Does your child roll? *

Yes
No
With Assistance

Does your child crawl? *

Yes
No
With Assistance

Does your child stand? *

Yes
No
With Assistance

Does your child pivot transfer? *

Yes
No
With Assistance

Does your child walk? *

Yes
No
With Assistance

Does your child propel wheelchair? *

Yes
No
With Assistance

What are your child's skills in bathing? *

Independent
Needs Assistance
Totally dependent

What are your child's skills in dressing? *

Independent
Needs Assistance
Totally dependent

What are your child's skills in toothbrushing? *

Independent
Needs Assistance
Totally dependent

What are your child's skills in hair care? *

Independent
Needs Assistance
Totally dependent

What are your child's skills in feeding? *

Independent
Needs Assistance
Totally dependent

Does your child have challenges with sucking? *

Yes
No

If your child has challenges with sucking, please explain: *

Does your child have challenges with swallowing? *

Yes
No

If your child has challenges with swallowing, please explain: *

Does your child have challenges with chewing? *

Yes
No

If your child has challenges with chewing, please explain: *

Does your child have challenges with gagging? *

Yes
No

If your child has challenges with gagging, please explain: *

Does your child have challenges with biting? *

Yes
No

If your child has challenges with biting, please explain: *

Does your child have challenges with lip closure? *

Yes
No

If your child has challenges with lip closure, please explain: *

Does your child have challenges with drinking? *

Yes
No

If your child has challenges with drinking, please explain: *

Does your child drink formula? *

Yes
No

If your child drinks formula, please list what kind(s): *

List your child’s favorite foods/flavors: *

List any foods/flavors your child dislikes: *

Behaviors

What does the applicant do when he/she is:

Happy *

Angry *

Scared *

Sick *

Hungry *

Wet/Soiled *

With other children *

Briefly describe your child's bedroom and other rooms in the home. *

(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. *

(With light or radio on? With stuffed animals? What size bed?)

Describe activities that your child enjoys: *

(Including outside activities like strolling, swinging, etc.)

Your child's daily routine: *

(Give approximate time of day)

What do you do when your child misbehaves? How do you discipline your child? *

What do you do to calm your child when he/she becomes upset? *

What family activities does your child enjoy the most? *

What is your child's least favorite activity? *

How does your child demonstrate dislikes? *

List favorite toys or objects and briefly describe: *

Please provide any other important information regarding your child which would be helpful to our staff *

Name of person completing application form *

Confirmation *

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 *

Birthdate *

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 *

Last Name *

Today's Date:

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