FSS Application

Date:
 / 
 / 
Parents/Gaurdians:
Address:
Does the family reside in Franklin County?
Is the family member currently enrolled in a Franklin County Board of Developmental Disabilities program?
If yes, name of program:
Physician Name & Address:
Relationship to person with DD:
Phone:
-
E-mail:
Date of Birth:
 / 
 / 
Social Security # :
Name of family member with developmental disabilities:
Does the family member with substantial developmental disability live at home with his/her family on a full-time basis?
If individual is school age, please indicate school district of attendance:
Physician Phone #:
-
Client Diagnosis:
Cause of disability (if known):
At what age did disability begin?
Check the following that best describe the individual: (Please check ALL answers that apply):
Name of other siblings in the home:
Mother/Caregiver:
Address of Mother/Caregiver:
Mother/Caregiver Home Phone:
-
Mother/Caregiver Work Phone:
-
Mother/Caregiver Place of Business:
Date of Birth of Sibilings
 / 
 / 
Father/Caregiver:
Address of Father/Caregiver:
Father/Caregiver Home Phone:
-
Father/Caregiver Work Phone:
-
Father/Caregiver Place of Business:
Emergency Contact #1
Emergency Contact #1 Name:
Emergency Contact #1 Home Address:
Emergency Contact #1 Relationship:
Emergency Contact #1 Cell Phone:
-
Emergency Contact #2
Emergency Contact #2 Name:
Emergency Contact #2 Home Address:
Emergency Contact #2 Relationship:
Emergency Contact #2 Cell Phone:
-
Emergency Contact #3
Emergency Contact #3 Name:
Emergency Contact #3 Address:
Emergency Contact #3 Relationship:
Emergency Contact #3 Cell Phone:
-
Physical Information
Height:
Is lifting required?
Weight:
Describe any current health concerns (i.e. allergies, Diabetes, shunt):
Medication #1
Name #1:
Dosage #1:
Purpose #1:
Color/Shape #1:
Time #1:
Medication #2
Name #2:
Dosage #2:
Purpose #2:
Color/Shape #2:
Time #2:
Medication #3
Name #3:
Dosage #3:
Purpose #3:
Color/Shape #3:
Time #3:
Medication #4
Name #4:
Dosage #4:
Purpose #4:
Medication Allergies:
Color/Shape #4:
Time #4:
Eating Habits:
Special positions while eating:
Food Allergies:
Special food preparation (i.e. strained, mashed):
Special diet (i.e. reducing, Diabetic, salt-free):
Special Feeding Instructions:
If no speech, how does the individual make wants known:
Is the individual diapered at night?
Other information (behavior, communication, special needs, etc):
How did you hear of this service?
Relationship to person with MR/DD :
Please check the amount of TAXABLE INCOME earned during the last calendar year.  As defined in the FAMILY SUPPORT SERVICES Rule, “taxable income” has the same meaning as it has for Federal Income Tax purposes.  Check your most recent Federal Income Tax Return for the amount of your taxable income.  If your income level changes, you should submit another Income Verification Update.
Taxable Income (Family Co-Pay %)

Boundless

ALTERNATE FUNDING IDENTIFICATION FORM

Boundless provides In-Home and Out of Home direct Respite Services in Franklin County.  Alternate funding options (Including Individual Options Waiver (I.O Waiver), Level One Waiver) that are available to enrolled families for Respite Services are to be identified before direct respite services are provided and/or upon enrollment in Boundless respite program.  Families receiving respite services are to complete this form and provide all needed information.  Incomplete or missing forms may result in the denial of respite services.  The individual/guardian/parent of the individual with DD must complete and sign the items below.

Check all that apply, complete all items: