Checklist for admittance of a new consumer.
The following checklist is what we will need to have before the admittance of a
new consumer to our program at the West Fork Services, Inc.
- Print CHECKLIST CLICK HERE
- Application (Click here for printable application)
- Care Contract
- Transfer Form
- Consumer Belonging's
- Consumer Rights
- Physical (Current with in 1 year)
- T.B. with in 30 days of move
- Physician's Certification (One for workshop and One for residential - Both signed by physician)
- Physician' certification to self administer medication - signed by physician
- Physician's certification to transfer medications - signed by physician
- PRN sheet - signed by physician
- Medications and refills or scripts until can be seen b local physician
- List of current medications
- Copies of any specialist appointments that may need to be ongoing.
- Copy of social security card
- Guardianship - if applicable
- Copies of T-19 and Medicare cards
- Burial trust
- Birth Certificate
- Social History
- Psychological Evaluation
- Current eye/dental -with in 1 year
- Copy of current Iowa ID
- Funding approval in writing for both workshop and residential
- Copies of current IPP's
- Any pertinent history or background that may be beneficial
- Money to open a checking account for personal needs.
Thank you so much. Please make sure you have all the above before your consumer can be admitted to our program.
Any questions you may have please contact me:
Sonya Middleton, Case Coordinator
21 North Taft Street
Humboldt, Iowa 50548
515-332-2841
E-mail me: sonyam@westforkservices.org
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