Pre-Admissions Referral Form - Imagine the Possibilities

Is this an URGENT referral?

Yes

No

"Urgent" is defined as the individual is at risk of losing their current service within the next 72 hours.

Individual's Name

First

Last

Today's Date

Individual's Date of Birth

Legal Gender

Male

Female

Prefer Not to Say

Other

Gender Identity

Male

Female

Other

Ethnicity (Select All That Apply)

White

Hispanic, Latino, or Spanish

Black or African American

Asian

American Indian or Alaska Native

Middle Eastern or North African

Native Hawaiian or other Pacific Islander

Prefer Not to Say

OtherOther

Primary Language Preference

Is this individual currently incarcerated?

Yes

No

Primary Diagnoses or Disability

Intellectual Disability

Chronic Mental Illness

Brain Injury

OtherOther

Level of Care Needed

Habilitation or ID/BI Waiver

RCF/PMI

Service Type

Does this individual require a handicap accessible home?

Does this individual have any environmental adaptations needed?

N/A

DME (Walker, Wheelchair, Toliet Chair, Hospital Bed, etc).

Electronic Assistive Devices (Communication Devices, Adaptive Switches, etc.)

Safety Systems (Wanderguard, Door Alarms, etc.)

Can this individual live in a co-ed home?

Individual's Home Address

City

State/Province

Zip/Postal

County

Service Area (Location) desired:

All Regions

Region 1 [Buena Vista, Pocahontas, Greene, Boone, Story, and Guthrie Counties]

Region 2 [Adams, Dallas County (Supported Employment Only) Madison, Union, and Taylor Counties]

Region 3 [Clayton and Delaware Counties]

Region 4 [Dubuque, Clinton, Jackson (Day Services and Vocational Services Only) Mahaska, Warren, and Tama Couties]

Region 5 [Clinton (Residential/Hourly Only), Jackson (Residential/Hourly Only), and Scott Counties]

Region 6 [Des Moines, Lee, Louisa, Henry, Jefferson (IPS Only), and Washington (IPS Only) Counties]

Reason for Referral

Current Living Situation and List of Current Services

Anticipated Funding/Tier

Please list any Imagine the Possibilities employees you have already spoken to about this individual:

Is this person currently on or has been registered as a sex offender in the past?

Yes

No

Trauma History:

History of Sexual Abuse

History of Physical Abuse

History of Neglect

History of Emotional/Psychological Abuse

None

Date of Last Dental Appointment:

Date of Last Annual Physical:

Name of Physician Who Completed Last Annual Physical:

Date(s)/Summary of Hospitalizations Over the Past Year:

Legal Status

History of Suicide Attempts

None