CDS Unistel : Warrior Salute Program Application

Warrior Salute

Warrior Salute Program Application

Date Service Needed:

(mm/dd/yyyy)

INDIVIDUAL

First Name:

Last Name:

Sex:

MaleFemale

Birth Date:

(mm/dd/yyyy)

Permanent Address

Street:

City:

State:

Zip:

Current Address Copy Permanent Address

Street:

City:

State:

Zip:

Phone:

Current Living Situation (In Rochester Area):

Need Housing Referral

Contact

First Name:

Last Name:

Phone:

E-mail:

Case Manager

First Name:

Last Name:

Phone:

Fax:

E-mail:

Agency

Name:

Street:

City:

State:

Zip:

SERVICES REQUESTED

Physical Therapy

Speech Language Therapy

Occupational Therapy

Counseling Services

VocationalorTransitionAssessments

Therapeutic Aquatics & Fitness

Employment Counseling

Computer Skills Training

Life Skills Coaching

Family Counseling

Education Referral

Other:

URGENCY OF NEED

ImmediateWithin 3 MonthsWithin 6 Months

BENEFITS

SSI

SSD

Public Assistance

Other Wages

Medicare #:

Medicare Part D Carrier:

Health Care Insurance Provider:

Other:

MEDICAL CONDITIONS

Traumatic Brain Injury

Neurological Impairment

Epilepsy (Type):

DSM Code:

Mental Health Diagnosis:

Physical Needs (Specify):

Other:

MOBILITY STATUS

Ambulatory

Uses Manual Wheelchair

Able To Negotiate Stairs

Requires Use of Lift

One-person Transfer

Several Person Transfer

Able To Bear Weight

Can Be Transported In A Car

Requires Vehicle With Life

ADAPTIVE EQUIPMENT

Commuincation Device

Wheelchair

Computer

Mobility Device

Eating Utensils

Lift

Hearing Aid

Eye Glasses

Other:

SERVICES CURRENTLY RECEIVING

Case Management

Psychiatry/Psychology

Counseling

Social Work

OccupationalTherapy

Speech Therapy

Physical Therapy

Nursing Services

Other: