CLC OD Form

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Fax completed form to: 608-960-4003

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REQUESTED SERVICES FOR
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Date of Birth DD/MM/YYYY
Gender
Ethnicity
- White
- Black
- Hispanic
- Native American
- Asian/Pacific Island
- Other/Unknown
Anticipated Start Date
Guardian(s) Name
Guardian(s) Phone Number
Guardian's Email
CLC Contact Person
CLC Phone Number
CLC Email
MCO/IC Provider
MCO Phone
MCO Email
FEA (if applicable)
Housemates (include names)
Do you have any pets?
If yes, what kind?
Are you a smoker?

Medical/Health
Diagnosis
Hospital of Choice
Medications (please indicate where the list can be located in the home, no need to list)
Can the individual administer his or her own medication?
Other Concerns? (Seizures, elopment, fall risk, food seeking, allergies, etc?) Please describe in detail.
Vision/Hearing Concerns?
Communication Concerns?
Mobility Concerns?
Can the individual use a phone independently?
Can the individual push a button for help?
Can this individual exit his/her house in an emergency independently?
Can this individual exit his/her house in an emergency if told so via phone?
Other medical/health concerns

Sleeping Patterns (if known)
Please describe sleeping pattern
Behavior Information
Behavior "issues"/challenges if any:
What level of service? (Level 1 - 4)
Equipment Neets/Responder Contact and Texting Info: (be specific with sensor type and name - Front door, fridge sensor, hallway motion, etc)
Your Info
Person Completing Form
First Last
Date

REQUESTED SERVICES FOR