Person in Need of Service
Last Name: First Name:
Gender:  Male   Female Date of birth:
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Current Address:
Street Name Street No. City State Zip Code Phone No.
Service Needed:
(Check all that apply)
 Behavioral  Supported Living  Nursing  Day Services
Current Agency:
(If any)
Phone No.:
Reason for Referral (check all that apply)
Skill Deficits
 Independent Living Skills 
 Communication Skills 
 Academic Skills 
 Self-Care Skills 
 Working Skills 
 Social Skills 
Challenging Behaviors
 Physical Aggression 
 Verbal Aggression 
 Property Destruction 
 Inappropriate Sexual Behavior 
 Refusal of Medical Attention 
 Severe Behavior Outbursts 
 Self-Injurious Behavior 
Subjective Assessment Of Risk And Need For Services In The Last 90 Days
Are any challenging behaviors life-threatening?  Yes   No
Do any challenging behaviors provide a health risk to the person?  Yes   No
Do any challenging behaviors interfere with learning?  Yes   No
Will any behaviors become serious in the near future if not treated?  Yes   No
Are any challenging behaviors dangerous to others?  Yes   No
Are any challenging behaviors of great concern to caregivers?  Yes   No
Are any challenging behaviors getting worse or not improving?  Yes   No
Has this been a problem for some time?  Yes   No
Do any challenging behaviors damage materials?  Yes   No
Do any challenging behaviors interfere with community acceptance?  Yes   No
Are psychotropic drugs used to control any challenging behavior?  Yes   No
Have any challenging behaviors resulted in police/court involvement?  Yes   No
Do any challenging behaviors interfere with the person's Quality of Life?  Yes   No
Would other positive behaviors improve if any of the challenging ones improved?  Yes   No
Did any challenging behaviors require medical/nurse attention in the last 90 days?  Yes   No
Did any challenging behavior result in property damage in the last 90 days?  Yes   No
Do any challenging behaviors require the use of protective equipment/restraint?  Yes   No
Do any challenging behaviors interrupt the individual's daily routine?  Yes   No
Legal Guardian's Name & No.:
Independent Support Coordinator & Agency:
Person Completing This Form:
Realtionship to indivdual:
Contact Information
Your email address:
Phone Number: