Smiles Like Yours Service Application
First Name:
*
Last Name:
*
Your Phone #:
*
Your Email:
*
WAMS ID
*
What services are you interested in?
*
Group Day
Community Engagement
Community Coaching
Residential Living
Service Plan Start Date
Service Plan End Date
First Quarter Date
Second Quarter Date
Third Quarter Date
Fourth Quarter Date
Enter Individuals Diagnosis Code*
Level
Tier
Does the individual display physical aggression towards others?
Yes
No
Behavioral Functioning
What supports are needed for this individual?
Legal Representation
Is the individual their own legal guardian
Yes
No
Who is the individuals legal guardian?
Individual Relationship With Guardian
Legal Guardians Email Address
Legal Guardians Contact Number
Authorized Agent Name
Individual Relationship With Agent
Authorized Agent Email Address
Authorized Agent Contact Number
Who is the individuals Support Coordinator
Support Coordinator Contact number
Support Coordinator email Address
Name of other involved family and or friends
Name of the person who will be responsible for paying the members monthly activity fee
The email address of the person responsible paying members monthly activity fee
Residential provider name
Residential Provider Email address
Residential Provider Phone number
Emergency Medical Information
Person to contact in case of an emergency
Person Relationship
Emergency Contact Phone Number
Enter Zip Code
Enter City
Enter State
Emergency Contact Address
Physicians Information
Current Physician
Physician Contact Number
Physician Address
Current Dentist
Dentist Phone Number
Dentist Address
Fax Number
Current Psychiatrist
Psychiatrist Phone number
Psychiatrist Fax Number
Psychiatrist Address
Insurance Information
Name of Medical Insurance Company
Policy number
Medicaid/Medicare/Champus number
Any allergies to medicine or food? If yes, please identify (medications and food)
Any history of substance abuse If yes, please explain
Does individual have significant ambulatory or sensory problems? If Yes Please Explain
Does the client have significant communication problems? If Yes Please Explain
Advance Directive if one exists?
Please upload the following files and mark completed once attached in the portal. All information will be sent securely through a private portal.
Upload State ID
Upload Social Security Card
Medicaid Eligibility Letter
Upload Current ISP
Upload VIDES
Upload SIS Report
Current Risk Assessment
Upload Comprehensive Diagnostic Assessment (If Applicable)
Upload Psychological Evaluation (If applicable)
Upload Seizure plan (if applicable)
Upload Fall Risk plan (If applicable)
Upload Behavior Plan (If applicable)
Upload Nutritional Protocol (if applicable)
Upload Physician Medication Order (if applicable)
Upload All Documents Here
PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF
Submit
