Member’s Form

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MEMBER INFORMATION

Last Name (Member)(Required)

First Name (Member)(Required)

Middle Initial

Member's email address (if applicable)

Member's Address(Required)

City(Required)

State(Required)

Zipcode(Required)

Gender(Required)

Preferred Pronouns

Date of Birth(Required)

Language Preference(Required)

Cultural Preference(s):

RACE/ETHNICITY: (Please select one of the descriptions below corresponding to the ethnic group with which you identify.)(Required)

Qualifying Diagnosis:(Required)

Other Diagnosis(s):

Responsible Party/Guardian Name/Relationship:(Required)

Phone(Required)

Email(Required)

Electronic Visit Verification (EVV) Device Preference Use (i.e. Mobile Device or FOB)(Required)

Does the Member have an Advanced Directive or Do Not Resuscitate (DNR)?(Required)

Yes

Where is it located?(Required)

Does the Member Smoke?(Required)

Yes

Does the Member Drink Alcoholic Beverages?(Required)

Yes

SERVICES & SCHEDULE (Check all applicable)

Days:(Required)

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Funding Source(Required)

DDD

EPD

Private Pay

Attendant Care (ATC) Weekly Hours

Companion Care Services (CCS) Daily Hours

Habilitation Services (HAH/ECH/HAI/HID) Weekly Hours

Housekeeping (HSK) Weekly Hours

Respite (RSP) Annual Allocation of Hours

Adult Developmental Home (ADH)

Daily coverage

Private Home Care Personal Care Weekly Hours

Private Home Care Independent Living Weekly Hours

SPECIALIZED TRAINING

Medication Administration Training Needed(Required)

Yes

Behavior Plan Training Needed(Required)

Yes

Mobility Training Needed(Required)

Yes

Feeding Training Needed(Required)

Yes

Seizure Management Training Needed(Required)

Yes

Prevention & Support Training Needed(Required)

Yes

Mobility/Transferring Training Needed(Required)

Yes

Is there any additional specialized training required?(Required)

Yes

If yes, describe:(Required)

GUARDIAN/RESPONSIBLE PERSON INFORMATION

Guardian’s/Responsible Person’s Name (Last, First, M.I.)(Required)

Relationship(Required)

Do you provide the direct care for your child?(Required)

Yes

Phone(Required)

Language Preference(Required)

Cultural Preference(s)

Address (No., Street, City, State, ZIP Code)(Required)

Emergency Contact’s Name (If other than responsible party)

Relationship

Phone

MEDICAL/BEHAVIOR HEALTH CONTACT INFORMATION

Name of ALTCS/DDD Health Plan(Required)

AHCCCS ID # (Required)

Phone #

Other Health Insurance Information

Primary Care Physician:(Required)

Physician’s Phone #:(Required)

Address (No., Street, City, State, ZIP Code)

Pharmacy

Pharmacy Phone #

Address (No., Street, City, State, ZIP Code)

Behavioral Health Provider

Behavioral Health Phone #

Urgent Care Facility/Hospice/Hospital:(Required)

Phone #

Urgent Care Address:(Required)

FUNDING SOURCE SUPPORT COORDINATION CONTACT

Support Coordinator/Case Manager Name(Required)

Support Coordinator/Case Manager Phone #(Required)

Support Coordinator/Case Manager Email(Required)

Office Location

Support Coordinator/Case Manager Supervisor

Support Coordinator/Case Manager Supervisor Phone #

Support Coordinator/Case Manager Supervisor Email

HEALTH-MEDICAL

*ACS providers are prohibited from administering medications with exception of ADH providers*

Medication Log Required:(Required)

Yes

Where can a list of current medication and any special instructions be found?(Required)

Allergies To:(Required)

N/A

Food

Bee/Insects

Medications

Other

Allergies (Food)(Required)

Please specify

Required Response to Allergic Reaction, provide any written orders for Health Care Professional

Seizures:(Required)

Yes

Description:(Required)

Describe what type of seizure and what they look like

Frequency:(Required)

Approximate Duration:(Required)

Required Response to Seizure Activity, provide any written orders for Health Care Professional(Required)

Nursing Services Required(Required)

Yes

Assistive Devices:(Required)

i.e Glasses, hearing aid, braces, dentures

Yes

Vision:(Required)

Glasses

Contacts

N/A

Hearing:(Required)

Hearing Aid

N/A

Other

Dental Appliances:(Required)

Dentures

Partials

Full

N/A

Urinary Catheter:(Required)

Yes

Special Instructions:

Ostomy:(Required)

Yes

Special Instructions:

Diabetic:(Required)

Yes

Diabetic (yes)(Required)

N/A

Pills

Injections

Reminders

General Special Instructions:

Skin integrity (Are there any skin integrity issues?):(Required)

Yes

What part of the body is it?(Required)

Is there a treatment plan in place and what is it?(Required)

Prescriber of Treatment(Required)

Is it documented in the ISP/Planning Document?(Required)

Yes

Other Individualized Health Care Routines

NUTRITION

Utensils(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Food Prep(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Bringing Food to Mouth(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Choking(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Understands Temperature of Food(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Other (Describe below)

Describe Any Special Dietary Requirements Including Food Consistency (i.e., chopped, pureed), Temperature, Calorie Needs or Write NA(Required)

DRINKING

Ability to Use Cup or Glass(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Ability to Use Adaptive Cup or Glass(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Able to Obtain or Request Beverages(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Understands Temperature of Beverages(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Choking(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Other (Describe below)

Describe Any Adaptive Drinking Equipment/Special Liquid Intake Needs (i.e., thickening agents)/System for Fluid Intake or Write NA:(Required)

SPECIAL DIET

Intake of Food via the Gastrointestinal (GI) Tract(Required)

(ACS Providers can only administer food/flush through GT tube. Special instructions required / check type and include special instructions)

Yes

GI Tract(Required)

Nasogastric Tube (NGT)

Orogastric Tube (OGT)

Nasoenteric Tube

Oroenteric Tube

Gastrostomy Tube

Jejunostomy Tube

Who will provide training by when?(Required)

Eating Disorder:(Required)

Yes

Describe type and support needed(Required)

Communication Skills (mark all that apply)(Required)

Uses complex sentences

Uses simple sentences

Signs

Nods yes/no

Gestures

Support needed(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Is the member non-verbal?(Required)

Yes

Describe Any Other Communication Requirements (if applicable)

Describe Augmentative Communication Devices (if applicable)

MOBILITY

Crawling/ Scooting(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Kneeling(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Standing(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Walking(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Running(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Climbing(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Other (Describe Below)

Mobility(Required)

(Balance while standing)

Excellent (not an issue)

Moderate (stumble, etc)

Poor (very unsteady, falls)

No Mobility (full assistance req)

Fall Risk(Required)

No Risk

Moderate (fall precaution)

Poor (fall risk)

No Mobility (high fall risk)

Mobility/Balance Aids Used(Required)

Yes

Select all that apply(Required)

AFO's

Manual Wheelchair

Power Wheelchair

Cane

Walker

Crutches

Leg Braces

Other

For any devices, who will provide the training and by when?(Required)

If other was selected explain

TRANSFER SUPPORT NEEDED(Required)

Yes

Height(Required)

Weight(Required)

Select all that apply(Required)

1 person Lift

2 person lift

Mechanical lift

Lift/Transfer less than 50lbs

Lift/Transfer more than 50lbs

Slide board

Gait Belt

Lifting/Carrying Instructions(Required)

Positioning Instructions(Required)

Enter Mechanical Lift Brand/Model (Ex: Hoyer Lift)(Required)

TRANSPORTATION SUPPORT NEEDED(Required)

Car Seat

Adaptive Vehicle Required

Other Transportation Needs

PERSONAL CARE

Select Level of Assistance Needed

Dressing/Undressing

Elastic(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Buttons(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Snaps(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Tying(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Zippers(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Toileting

Toilet(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Beside Commode(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Bedpan/urinal(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Chux(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Depends(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Diapers(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Bathing

Tub(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Shower(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Bed bath(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Sponge bath(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Bath seat(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Oral Care

Brush Teeth(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Dentures-Full(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Dentures-Partial(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Hair Care

Shampoo(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Brush/Comb(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Dry Hair(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Shaving(Required)

Yes

Level of Assistance Needed(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Describe shaving method:(Required)

Females only

Menses(Required)

Yes

Level of Assistance Needed(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Untitled(Required)

Sanitary napkin

Tampon

Other

If other is select, please explain(Required)

Nail Care

Clean & File(Required)

(Do not cut toenails if Diabetic)

Yes

Level of Assistance Needed(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Skin Care

Lotion Application(Required)

Yes

Level of Assistance Needed(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Frequency(Required)

Medication

Medication Administered by(Required)

Self

Family

Other

Level of Assistance Needed(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Full Name and Relationship of individual administering medication(Required)

Financial

Member manages own finances(Required)

Yes

Level of Assistance Needed(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

If no, Responsible Party Name and Phone #(Required)

Telephone

Dialing(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Accepting Calls(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Community Access

Getting in/out of vehicle or public transport(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Outings

Grocery shopping, Dr. appointments, activities, etc(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Home

Housework/Environmental Safety(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Laundry(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Light Housekeeping(Required)

Independent, no support required

Prompting/Reminding Required

Limited Assistance/ Supervision Required

Significant Assistance/ Supervision Required

Describe Special Personal Care Needs and Preferences or Write NA:

Behavior

BEHAVIORAL CONCERNS (If applicable)

Verbal Aggression(Required)

Yes

Intensity(Required)

Severe

Moderate

Mild

Frequency(Required)

Topography (what does the behavior look like)(Required)

Recommended Intervention(Required)

Physical Aggression(Required)

Yes

Intensity(Required)

Severe

Moderate

Mild

Frequency(Required)

Topography (what does the behavior look like)(Required)

Recommended Intervention(Required)

Self -Injurious Behavior(Required)

Yes

Intensity(Required)

Severe

Moderate

Mild

Frequency(Required)

Topography (what does the behavior look like)(Required)

Recommended Intervention(Required)

Property Destruction(Required)

Yes

Intensity(Required)

Severe

Moderate

Mild

Frequency(Required)

Topography (what does the behavior look like)(Required)

Recommended Intervention(Required)

Member Leaves Area without informing anyone(Required)

Yes

Intensity(Required)

Severe

Moderate

Mild

Frequency(Required)

Topography (what does the behavior look like)(Required)

Recommended Intervention(Required)

Flight Risk(Required)

Yes

Intensity(Required)

Severe

Moderate

Mild

Frequency(Required)

Topography (what does the behavior look like)(Required)

Recommended Intervention(Required)

Self - Stimulation(Required)

Yes

Intensity(Required)

Severe

Moderate

Mild

Frequency(Required)

Topography (what does the behavior look like)(Required)

Recommended Intervention(Required)

Sexual Acting Out(Required)

Yes

Intensity(Required)

Severe

Moderate

Mild

Frequency(Required)

Topography (what does the behavior look like)(Required)

Recommended Intervention(Required)

Extreme Liquid/ Food Seeking(Required)

Yes

Intensity(Required)

Severe

Moderate

Mild

Frequency(Required)

Topography (what does the behavior look like)(Required)

Recommended Intervention(Required)

Ingesting Non-Edible Objects(Required)

Yes

Intensity(Required)

Severe

Moderate

Mild

Frequency(Required)

Topography (what does the behavior look like)(Required)

Recommended Intervention(Required)

Difficulty with Transitions(Required)

Yes

Intensity(Required)

Severe

Moderate

Mild

Frequency(Required)

Topography (what does the behavior look like)(Required)

Recommended Intervention(Required)

Difficulty Understanding Consequences(Required)

Yes

Intensity(Required)

Severe

Moderate

Mild

Frequency(Required)

Topography (what does the behavior look like)(Required)

Recommended Intervention(Required)

Substance Abuse – Drug, Alcohol, Other(Required)

Yes

Intensity(Required)

Severe

Moderate

Mild

Frequency(Required)

Topography (what does the behavior look like)(Required)

Recommended Intervention(Required)

Other

Intensity

Severe

Moderate

Mild

Frequency

Topography (what does the behavior look like)

Recommended Intervention

Is a Behavioral Treatment Plan (BTP) Available for Additional Information:(Required)

Yes

Is Prevention and Support Required(Required)

Yes

Reason for Behavior Treatment Plan:(Required)

Behavior Treatment Plan Authored by (Agency)(Required)

Method Used to Obtain Information (e.g., in person, case file)(Required)

Is there a Functional Behavior Assessment (FBA) Available for Additional Information(Required)

Yes

Is there a Crisis Intervention Plan Available for Additional Information(Required)

Yes

Is there additional Behavior Health Support provided through the Health Plan(Required)

Yes

Where is the additional information saved (e.g., in person, case file)(Required)

Protective Devices

Protective Devices Used(Required)

Yes

Prescription on File(Required)

Yes

PRC Approval Date(Required)

MM slash DD slash YYYY

Instructions for Use(Required)

Purpose(Required)

SUPERVISION SUPPORT

Unsupervised Time Alone(Required)

Yes

Constant Supervision Required(Required)

Yes

Duration of unsupervised time (hours)(Required)

Please enter a number less than or equal to 24.

Days of week:(Required)

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Location:(bedroom (door locked), anywhere in home, community)(Required)

The supervision of this member is based on the assessed needs as defined on the Risk Assessment of the Planning Document: Constant supervision is required:(Required)

Yes

EMPLOYMENT/DAY PROGRAM (If applicable)

Attending Employment or Day Program (DTA)?(Required)

Yes

Name of Employment or Day Program(Required)

Program Type(Required)

Program Address (No., Street, City, State, ZIP Code)(Required)

Phone #(Required)

Days and Hours of Attendance(Required)

Transportation Method(Required)

Any special staffing needs

OTHER PERTINENT INFORMATION

Do other individuals live in the home with the member?(Required)

Yes

List who lives in the home and their relationship:(Required)

Are there any animals in the home?(Required)

Yes

List any animals in the home:(Required)

Electronic Monitoring System :(Required)

Yes

Devices used (camera in residence, medical alert, etc.):(Required)

WEAPONS

Weapons are safeguarded:(Required)

Yes

N/A

Firearms are locked in an unbreakable container:(Required)

Yes

N/A

Firearms are trigger-locked or rendered inoperable:(Required)

Yes

N/A

Ammunition is locked separate from firearms:(Required)

Yes

N/A

Are there weapons in the home?(Required)

Yes

Power of Attorney/POA(Required)

Yes

Guardianship (court ordered)(Required)

Yes

Name(Required)

Email(Required)

Phone(Required)

POA or Guardianship Documents Attached(Required)

Yes

Upload POA or Guardianship Documents

Max. file size: 300 MB.

Member Interview

The member should complete this section. If the member is unable to, the person who knows the member best should complete this section with as much member input as possible.

Share the member’s favorite activities (music, movies, shopping, puzzles, etc.)(Required)

What are some of the member’s favorite foods?(Required)

What events are exciting for the member?(Required)

How does the member prefer to relax?(Required)

What is important to the member (educational goals, play time, alone time, vocational goals, pets etc.)?(Required)

What support does the member need in order to reach goals and/or participate in favorite activities?(Required)

What characteristics does the member want to see in their provider (punctual, high-energy, lower energy, talkative, quiet etc.)?(Required)

What activities does the member dislike?(Required)

Any additional comments?

PROVIDER INFORMATION

Provider’s Name (Last, First, M.I.)

Qualified Vendor: Arion Care Solutions Qualified Vendor Address: 3200 N. Dobson Rd, Ste F2 Chandler, AZ 85224

Emergency Contact (ACS Supervisor)

Phone #

After Hours Phone Number: 877-307-4668

Staff Will
Observe universal precautions and provide general safety supervision.

By signing this document, each party acknowledges that the information contained herein is true and correct. All parties have been provided the opportunity to ask any questions and understand all answers and all parties agree to comply with this agreement. It is also acknowledged that digital (electronic) signature is intended to authenticate this writing and to have the same force and effect as a manual signature. This document will act as a mutual agreement between parties for provision of services.

Name of Person Completing Form (if not Responsible Party):(Required)

Date(Required)

Relationship:(Required)

Member/Responsible Person (Print)(Required)

Member/Responsible Person (Sign)(Required)

A typed name in this field will be accepted as a signature.

Date(Required)

Is the provider a family member?

Yes

If the provider is a family member, do they live with the member?

Yes

What is the provider’s relationship to the member?

Date

MM slash DD slash YYYY

For ACS Use

Last Date Updated/Reviewed

MM slash DD slash YYYY

Reviewer (ACS Management)

CONNECT WITH US:

Member’s Form

MEMBER INFORMATION

SERVICES & SCHEDULE (Check all applicable)

SPECIALIZED TRAINING

GUARDIAN/RESPONSIBLE PERSON INFORMATION

MEDICAL/BEHAVIOR HEALTH CONTACT INFORMATION

FUNDING SOURCE SUPPORT COORDINATION CONTACT

HEALTH-MEDICAL

NUTRITION

DRINKING

SPECIAL DIET

MOBILITY

PERSONAL CARE

Dressing/Undressing

Toileting

Bathing

Oral Care

Hair Care

Females only

Nail Care

Skin Care

Medication

Financial

Telephone

Community Access

Outings

Home

Behavior

Protective Devices

SUPERVISION SUPPORT

EMPLOYMENT/DAY PROGRAM (If applicable)

OTHER PERTINENT INFORMATION

WEAPONS

Member Interview

PROVIDER INFORMATION