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574.848.7451
|
info@adecinc.com | Serving Elkhart and St. Joseph Counties
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NEWS
DONATE
PROGRAMS
DAY SERVICES
EMPLOYMENT SERVICES
GUARDIANSHIP
RESIDENTIAL
SKILLS TRAINING AT THE HUB
SUMMER CAMP
THERAPIES
TRANSPORTATION
AFTER SCHOOL
WORK FOR ADEC
APPLY NOW
JOB INFO
ADEC Industries
COMMUNITY
ART BY ADEC
CONFERENCE CENTER
GAINING GROUNDS COFFEE SHOP
HIRE AN ADEC CLIENT
Project SEARCH
SELF-ADVOCATES OF ADEC
SILVER BULLETS
SILVER LININGS TRASH BAGS
GET INVOLVED
CONTACT US
NEWSLETTER
VOLUNTEER
RESOURCES
ADEC GEAR STORE
ADEC YOUTUBE
ANNUAL REPORT
HISTORY
LEADERSHIP TEAM
REPORT ABUSE OR NEGLECT
RESOURCES FOR PARENTS AND GUARDIANS
STRATEGIC PLAN
990 PUBLIC DISCLOSURE
GROUP HEALTH PLAN- machine readable files
HIPAA Notice of Privacy Practices
Search for:
NEWS
DONATE
PROGRAMS
DAY SERVICES
EMPLOYMENT SERVICES
GUARDIANSHIP
RESIDENTIAL
SKILLS TRAINING AT THE HUB
SUMMER CAMP
THERAPIES
TRANSPORTATION
AFTER SCHOOL
WORK FOR ADEC
APPLY NOW
JOB INFO
ADEC Industries
COMMUNITY
ART BY ADEC
CONFERENCE CENTER
GAINING GROUNDS COFFEE SHOP
HIRE AN ADEC CLIENT
Project SEARCH
SELF-ADVOCATES OF ADEC
SILVER BULLETS
SILVER LININGS TRASH BAGS
GET INVOLVED
CONTACT US
NEWSLETTER
VOLUNTEER
RESOURCES
ADEC GEAR STORE
ADEC YOUTUBE
ANNUAL REPORT
HISTORY
LEADERSHIP TEAM
REPORT ABUSE OR NEGLECT
RESOURCES FOR PARENTS AND GUARDIANS
STRATEGIC PLAN
990 PUBLIC DISCLOSURE
GROUP HEALTH PLAN- machine readable files
HIPAA Notice of Privacy Practices
Therapy Application
2019-10-21T15:40:45-04:00
Therapy Application
Hidden
Date
MM slash DD slash YYYY
Therapy being considered (check all that apply):
*
Behavior
Music
Recreation
BASIC INFORMATION
Enter information below as it pertains to the individual served whom is requesting services.
Name of individual served:
*
First
Last
Date of birth of individual served:
*
Month
Day
Year
Case manager / Company name:
*
Case manager email address
*
Last four digits of SSN for individual served:
*
Permanent address of individual served:
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Parent / Guardian name:
*
First
Last
Parent / Guardian email address:
*
Primary phone number:
*
Best contact days and times:
*
Primary diagnosis:
*
Reason for referral:
*
DETAILED INFORMATION:
Answer the questions below to give us a better idea of the specific needs of the person applying for services.
Limitations with fine / gross motor skills?
*
Yes
No
Difficulty completing tasks of daily living?
*
Yes
No
Difficulty in meeting developmental milestones?
*
Yes
No
Difficulty in sustaining attention to tasks?
*
Yes
No
Difficulty applying skills learned?
*
Yes
No
Limited in expressive / receptive language skills?
*
Yes
No
Ability to speak using words?
*
Yes
Some
None
Engages in sensory seeking behavior?
*
Yes
No
Unknown
Difficulty imitating or engaging with others?
*
Yes
No
Emotional / behavioral disturbances that create barriers to completing tasks?
*
Yes
No
Challenges with responding positively to directions?
*
Yes
No
Difficulty displaying expected emotional response?
*
Yes
No
Any incident reports in the past 90 days?
*
Yes
No
List any other therapies currently being received (OT, PT, SLP, behavior management, etc.):
*
Is there a behavior plan already in place for other therapies being received?
*
Yes
No
Unknown
N/A
Additional information:
*
Consent agreement:
*
I agree to the privacy policy.
By checking this box, I understand that this application is part of a screening process to determine if behavior management, music therapy, or recreational therapy is appropriate for the individual named in this application. I understand that completing this application does not guarantee therapy services will be provided by ADEC Inc. I understand that by completing this application, I am giving ADEC Inc. permission to contact me regarding therapy services.
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