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PRE-ADMISSION ASSESSMENT FORM

INSTRUCTIONS: Please complete all sections and submit this form.

If you prefer to print and complete this form by hand, you may download it here.

General Information

Date of Application(Required)

MM slash DD slash YYYY

Desired Start Date:(Required)

MM slash DD slash YYYY

Name(Required)

First Last

D.O.B:(Required)

MM slash DD slash YYYY

Medical Assistance Number:(Required)

SS Number(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Applicant’s Home Phone:(Required)

Applicant’s Cell Phone:(Required)

Applicant’s Email(Required)

Requested Services:(Required)

Community Residential Services

Supported Living

Personal Supports

Respite

Day Habilitation (facility)

Day Habilitation (community)

Community Development Services

Employment Services

Career Exploration

Retirement / in-home

Transportation only

County:(Required)

Frederick

Washington

Physician’s Information

Physician Name:(Required)

Phone:(Required)

Practice Name(Required)

Physician’s Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is the applicant his/her own guardian?(Required)

Yes

No

who is the current guardian:

current guardian Name:(Required)

current guardian Phone:(Required)

current guardian Email:(Required)

Is the applicant currently receiving services?(Required)

Yes

No

Please list services and current provider

Does the applicant have a case manager or service coordinator?(Required)

Yes

No

List Name:(Required)

Agency Name:(Required)

Phone Number(Required)

Emergency Contact Information: (Please list two, if possible)

Emergency Contact (Name):(Required)

Emergency Phone:(Required)

Cell Phone:

Alternate Emergency Contact: (Name)

Emergency Phone:

Cell Phone:

Preferred method of contact:(Required)

Phone

Email

Text

Applicant’s Medical Information

Medical History:

Patient Diagnoses:

Medications

List Medications, Dosage, Frequency, Route, and Specific Reason for Medication below (include medications that are taken as needed):

Is the applicant able to self-medicate?(Required)

Yes

No

Please specify and include a Doctor’s order stating that the applicant can self-medicate

SOCIAL & BEHAVIOR

Please specify any social/behavioral challenges:(Required)

Line of sight supervision

Close supervision

May be alone for:

min/hrs

social/behavioral challenges

Verbal Aggression

Physical Aggression

Self-Injury

Property Destruction

Elopement

Eating Inedible Items

Requires 1:1 staffing

Requires 2:1 staffing

Person Completing This Form(Required)

Date(Required)

MM slash DD slash YYYY

Relationship to Applicant

• Pre-admission form is only valid within 60 days of a DDA admission.
• HDC requires that all residents living in HDC homes have HDC as their representative payee.

If you prefer to print and complete this form by hand, you may download it here.

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Hagerstown

433 Brewer Avenue

Hagerstown, MD 21740

301.791.5421
Frederick

5430 Mt. Zion Road

Frederick, MD 21703

301.898.2351

©2024 Washington County Human Development Council
The HDC is committed to ensuring that no person shall, on the grounds of race, color, national origin, as provided by the Title VI of the Civil Rights Act of 1964 and the Civil Rights Restoration Act of 1987 (PL 100.259), be excluded from participation in, be denied the benefits of, or otherwise subjected to discrimination under any program or activity, whether those programs and activities are federally funded or not. For more information on HDC's nondiscrimination policies and procedures, please contact our Title IV Manager at 433 Brewer Avenue, Hagerstown, MD 21740. Website by WORX