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Fill in Your Rem Iowa Service Application Template

The REM Iowa Service Application form is a crucial document for individuals seeking developmental and mental health services in Iowa. This form collects essential information about the applicant, including their diagnosis, financial status, and desired services. Completing this application accurately helps ensure that individuals receive the support they need in a timely manner.

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Fill in Your Rem Iowa Service Application Template

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Similar forms

The Individualized Service Plan (ISP) is a document that shares similarities with the Rem Iowa Service Application form. Both documents are designed to assess an individual's needs and preferences regarding services. The ISP outlines specific goals and objectives tailored to the individual, ensuring that the services provided align with their unique circumstances. Like the Rem Iowa form, the ISP requires detailed personal information, including medical history and current living situations, to develop a comprehensive plan for care and support.

When dealing with the sale of a trailer, having a properly executed Trailer Bill of Sale form is essential to ensure a smooth transaction. This legal document not only records the sale and transfer of ownership but also provides a comprehensive record that details the terms of the sale, including the identities of both the buyer and seller. For those looking to formalize the sale process, it is highly recommended to visit https://billofsaleforvehicles.com/editable-trailer-bill-of-sale/ for a customizable template that suits individual needs.

The Application for Benefits is another document that parallels the Rem Iowa Service Application. This form is used to determine eligibility for various assistance programs. Both forms require personal details, financial information, and medical history to evaluate the applicant's needs. The Application for Benefits focuses on financial assistance, while the Rem Iowa form emphasizes service eligibility, but both aim to ensure that individuals receive the support they need.

The Medicaid Application is similar to the Rem Iowa Service Application in that it seeks to gather information to establish eligibility for services. Both documents require applicants to provide personal information, including income and medical conditions. The Medicaid Application specifically assesses financial eligibility for healthcare services, while the Rem Iowa form focuses on identifying the appropriate community services for individuals with developmental disabilities or mental health issues.

The Case Management Referral Form also shares commonalities with the Rem Iowa Service Application. This form is utilized to initiate the case management process, gathering essential information about the individual’s needs. Both documents require detailed personal data and history of services received. The Case Management Referral Form is more focused on connecting individuals to appropriate resources, while the Rem Iowa form is centered on applying for specific services.

The Health Assessment Form is another document that aligns with the Rem Iowa Service Application. Both forms collect comprehensive health information to evaluate the applicant’s needs. The Health Assessment Form typically includes questions about medical history, medications, and any disabilities. This information is crucial in determining the appropriate level of care and services, similar to the goals of the Rem Iowa application.

The Family Support Application is comparable to the Rem Iowa Service Application in that it seeks to understand the family dynamics and support systems of the individual. Both documents require information about family members, their roles, and any financial assistance received. The Family Support Application focuses more on the family’s ability to provide care, while the Rem Iowa form emphasizes the individual’s specific service needs.

Finally, the Service Coordination Plan bears resemblance to the Rem Iowa Service Application. This plan outlines the coordination of services for individuals with disabilities, ensuring that all aspects of care are addressed. Both documents require detailed information about the individual's needs, preferences, and current services. The Service Coordination Plan emphasizes the collaboration between various service providers, while the Rem Iowa form focuses on the application process for specific community services.

Documents used along the form

The REM Iowa Service Application form is an essential document for individuals seeking services related to intellectual disabilities, developmental disabilities, or mental health. Along with this form, several other documents may be required to support the application process. Each of these documents provides crucial information that helps assess eligibility and determine the appropriate services needed.

Psychological Evaluation: This report outlines the applicant's mental health status and cognitive abilities, helping to establish the need for services.
Promissory Note: A critical component for securing loans, the promissoryform.com/ provides the necessary template to document the borrower's commitment to repay the lender.
Education Report: This document details the applicant's educational history, including any special education services received, which can influence the type of support needed.
Vocational Report: A vocational assessment provides insights into the applicant's work history and skills, aiding in the development of employment-related services.
Progress Reports: These reports summarize the applicant's progress in previous services, offering a history of their development and needs.
Medical Examination Records: Recent physical or specialty medical examinations provide information on the applicant's health status and any medical conditions that may affect service delivery.
Financial Documentation: Proof of income or financial assistance helps determine eligibility for funding and services.
Guardianship Documents: If applicable, these documents confirm the legal guardian's authority to act on behalf of the applicant.
Emergency Contact Information: This document lists individuals who can be contacted in case of emergencies, ensuring the safety and well-being of the applicant.
Consent Forms: Signed consent forms allow the sharing of necessary information between agencies and service providers, facilitating a smoother application process.
Additional Supporting Documents: Any other relevant documents that may assist in evaluating the applicant’s eligibility for services can also be included.

Gathering these documents ensures a comprehensive review of the application, allowing for the best possible support and services to be provided. Each document plays a vital role in understanding the applicant's unique needs and circumstances.

Dos and Don'ts

When filling out the Rem Iowa Service Application form, there are important guidelines to follow. Here’s a list of things to do and avoid:

Do provide accurate and complete information about the applicant.
Do ensure that all sections of the form are filled out, including contact details and diagnosis.
Do attach any relevant documentation that may support the application, such as medical evaluations.
Do double-check the form for errors before submission.
Don't leave any required fields blank; incomplete forms may delay processing.
Don't provide misleading or false information, as this can impact eligibility.
Don't forget to sign and date the form where required.
Don't wait until the last minute to submit the application; allow time for any necessary follow-ups.

Document Preview Example

REM IOWA COMMUNITY SERVICES & REM IOWA DEVELOPMENTAL SERVICES

SERVICE APPLICATION FORM FOR ID/DD/MH SERVICES

Date of Application:

REFERRAL TO REM IOWA

How did you become aware of REM Iowa services?

Family | Friend

REM Iowa website

The MENTOR Network website

Hospital

REM Employee

Other Provider

Case Manager | Care Coordinator

Other

If other, please document from whom/where:

APPLICANT INFORMATION

Applicant’s Full Name:

When Desired:

Placement in Jeopardy

Next Available

Within six months

Within one year

If placement in jeopardy, indicate the date of discharge:

Current Address:

Telephone Number:

Birth Date:

Gender:

Male

Female

Height:

Weight:

lbs.

Primary Diagnosis:

Intellectual Disability

Mental Health/Illness

Autism Spectrum:

Yes

Personality Disorder:

Yes

Schizophrenia or Schizoaffective Disorder:

Yes

Other Diagnosis:

LEGAL GUARDIANSHIP STATUS

Does this applicant have a guardian?

Yes

Name of Guardian:

Relationship:

FINANCIAL RESPONSIBILITY

Case Manager | Care Coordinator Name:

Telephone Number:

Email:

IME Determination Date:

Level of

Care:

SERVICE(S) DESIRED

Type of Services Desired:

ICF/ID

24-hour Waiver (Adult)

24-hour Habilitation

Host Home**

Communities desired:

Day Habilitation (*indicates available communities below)

Unknown

1. Children ICF/DD (ID must be primary diagnosis):

Council Bluffs Only

Adult ICF/DD (ID must be primary diagnosis):

1st Opening

Shelby

Washington

Coralville

Cedar Rapids | Marion | Hiawatha

No preference

Waiver Services:

1st Opening

Des Moines Area*

Mt. Pleasant

Atlantic

Ft. Madison

Mt. Vernon

Avoca

Harlan

Shelby

Cedar Rapids |Marion| Hiawatha*

Iowa City|Coralville*

Tipton

Clinton

Keokuk

Vinton*

Council Bluffs

Marshalltown*

Waterloo | Cedar Falls |Waverly

Davenport | Bettendorf

Mason City

No Preference

Other community (s):

**Host Home is a service where individuals live in private family homes and receive specialized assistance from a dedicated caregiver we call a Mentor.

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Revised 03.17

HISTORY OF SERVICES

Residential/ in-home services (e.g. hourly services, 24-hour waiver, ICF/ID, nursing home, etc.)

Has the applicant always lived at home?	Yes	No

Service	Provider

Dates

Day/Vocational Services
Has the applicant ever been employed:	Yes	No	At a day program?	Yes	No

Service

Provider

Dates

REFERRAL HISTORY

Has the applicant ever been arrested?

Yes

If yes, provide: Date(s):

Reason(s):

Outcomes:

Does the applicant have a current court committal?	Yes	No
Has the applicant been accused/convicted of sexual abuse?			Yes	No
If yes, provide: Date(s):
Outcomes:
Has the applicant had any history of cruelty to animals?			Yes	No
If yes, provide: Date(s):
Outcomes:
Has the applicant attempted suicide or had suicidal ideations?			Yes	No
If yes, provide: Date(s):
Outcomes:
Has the applicant had any history of fire setting?			Yes	No
If yes, provide: Date(s):
Outcomes:
Has the applicant had any history of cutting self, swallowing or insertion of foreign objects or			Yes	No
strangulation?
If yes, provide: Date(s):
Outcomes:
Has the applicant had physical aggression that required physical, mechanical or chemical restraint
via injection over the past 12 months?			Yes	No

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Revised 03.17

FAMILY INFORMATION

Mother’s Name (first & last):

Address:

Home Telephone #:

Work Telephone #:

Email Address:

Father’s Name (first & last):

Address:

Home Telephone #:

Work Telephone #:

Email Address:

Sibling’s Full Name(s) (first & last):

Significant Other Name (first & last):

Address:

Home Telephone #:

Work Telephone #:

Email Address:

APPLICANT’S FINANCIAL INFORMATION

Receive Financial Assistance:

Yes

If yes, type:

SS (Social Security)

SSI (Supplemental Social Insurance)

If other, document type:

VA (Veteran’s Benefits)

Child Support

Adoption Subsidy

Other

Does applicant have Title 19?

Yes

Managed Care Organization (MCO)?

Amerihealth Caritas

Amerigroup

United Health

Optum N/A

Does applicant have Waiver funding?

Yes

Does applicant have Habilitation funding?

Yes

Does applicant have private insurance?

Yes

Does applicant have other income (trust fund, etc.)?

Yes

APPLICANT’S HEALTH/MEDICAL INFORMATION

Current Medication(s) or can attach current medication orders or record:

Name	Dose	Frequency	Reason for Taking

Prescribed By

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Revised 03.17

Physical disabilities that require the use of adaptations (e.g. AFOs {braces}, orthopedic shoes, cane, walker, wheelchair,

etc.)	Yes	No
If yes, list adaptive equipment:
Seizures:	Yes	No	History of
If yes or history of, describe type and frequency:
Vision Problems:		No	Yes – correctable with glasses		Yes – but chooses not to wear glasses
		Yes - uncorrected		Blind Comments:
Hearing Problems:		No	Yes – correctable with hearing aides		Yes – but chooses not to wear hearing aides
		Adapt by others speaking louder			Deaf

Comments:

Skill Checklist: (please check items which best describe applicant)

BEHAVIOR	Consistently Sometimes Never Comments
Becomes upset when
redirected/corrected
Demands excessive
attention from others
Complains of being
persecuted
Pretends to be ill
Changes mood without reason
Bosses or manipulates others
Hyperactive
Hoards things
PICA (eats inedible objects) (if
displays, list items in
comments)
Self stimulation
Self injurious behavior
Verbally aggressive
Physically aggressive toward
others
Physcially aggressive toward
objects
Displays sexually inapprorpriate
behavior
Removes clothing in public
Tears clothing
Steals other's belongings
Elopes / runs away from home
Uses tobacco
Uses alcohol
Uses other drugs

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Revised 03.17

LEISURE ACTIVITIES

Interests:

Hobbies:

Dislikes:

CLOSING

The information we have asked you to provide is necessary for the effective administration of the services for which you are applying. The information collected will only be used by authorized agency personnel. Use of this information for purposes other than expressed herein will not occur without your prior written approval, unless such other use is specifically authorized by law.

Attach any of the following materials that may be helpful in determining eligibility for service:

Most recent psychological evaluation

Most recent education and/or vocational report

Most recent progress reports or plan of care

Physical and/or specialty medical examinations

Other Documentation that you feel would be helpful


Completed by:
Applicant Name:					Date:
Case Manager Name:					Date:
Parent/Guardian Name:					Date:
Name/Title:					Date:

Please return form to: REM Iowa (please check website for current contact information @ www.remiowa.com)

or send to REMIowaReferral@thementornetwork.com

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Revised 03.17