Community Engagement Intake Form

Participant Information

Full Name

Preferred Name / Nickname

Date of Birth

Age

Gender

Medicaid Number

Waiver Type

Primary Diagnosis

Secondary Diagnosis(es)

Address

Phone Number

Email Address

Preferred Method of Communication

Phone

Text

Other

Other Communication Method

Legal Representative / Emergency Contact

Name

Relationship to Participant

Phone Number

Email Address

Address if Different

Physician & Medical Information

Primary Care Physician

Physician Phone Number

Preferred Hospital

Allergies

Current Medications - Medication, Dosage, Frequency, Purpose

Special Medical Needs / Concerns

Support Needs

Other Assistance Needed

Communication Style / Preferences

Behavioral Triggers or Concerns

Calming / Support Strategies That Work Best

Community Engagement Interests

Other Activities

Participant's Goals for Community Engagement

Preferred Days / Times for Services

Transportation Information

Transportation Needs

Participant transports independently

Family transports participant

Transportation provided by FFS

Public transportation training/support needed

Special Transportation Instructions

Safety & Risk Information

History of Elopement / Wandering

Yes

History of Aggression

Yes

Seizure History

Yes

If yes, please explain

Other Safety Concerns

Consent & Authorization

I understand that Foundations Family Services provides Community Engagement services designed to support community inclusion, skill building, relationship development, and independence in integrated community settings.

I authorize Foundations Family Services to obtain and exchange information as needed for service coordination and treatment planning.