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Enrollment Form- Residential

Enrollment Form- Residential

1Getting Started

2Services Desired

3Person Served

4Diagnosis, Funding & Transport

5Team Information

6Personal Care & Support Needs

7Vocational Information

8Additional Information

9Upload Paperwork

Getting Started
During this application you will be asked for demographic and funding information about the individual with a disability, contact information for the individual’s team, support needs for the individual, and general questions about the individual’s social and employment history. At the end of the application you will be asked to upload documents related to the individual including (when applicable):
- Individual Abuse Prevention Plan (IAPP)
- Coordinated Service and Support Plan (CSSP) and Community Support Plan (CSP), or Individualized Education Program (IEP), or Individualized Support Plan (ISP)
- Proof of Disability: A psychological evaluation or diagnostic report (written and signed by a doctor/psychologist/psychiatrist) which states the person’s disabilities
- Positive Support/Behavior Plan
- Vocational Rehabilitation Services (VRS) Closure Paperwork
- Relevant Work/School/Residential Reports
This application cannot be saved, so please gather all available information before you begin. The application will take about 15-45 minutes to complete.

Questions? Contact referrals@opportunities.org or 952-938-5511

Services Desired
Select Services
- Group Home
- Homebase Supported Apartment
- In-Home Services

Person Served
First Name*
Last Name*
- This is the person inquiring
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Phone
Email
Gender*
Race*
Marital Status*
Current Residential Placement*

Diagnosis
Primary Diagnosis*
Secondary Diagnosis
Any Adaptive Equipment (ex. Walker, Communication Aides)?*
- Yes
- No
If yes, please explain:
Funding
Funding Source*
If you selected "Other/Unknown" above, please explain:
PMI/Medical Assistance Number*
Waiver Renewal Date*
MM slash DD slash YYYY
County of Financial Responsibility*
Do You Currently Have Housing Supports?*
- Yes
- No
- Unknown

Guardian
Select Guardian*
Relationship to Individual*
Name*
First Last
- This is the person inquiring
- Address is same as person served
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Guardian Email*
If you do not have an email, put N/A
Case Manager
Select Case Manager
Name*
First Last
- This is the person inquiring
County/Organization
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Financial Manager
Is There a Financial Manager?
- Add Financial Worker
- Unknown
Financial Worker's Name*
Put unknown if unknown
Other Team Member
Do you need to add another team member?
- Add another team member
Name*
First Last
- This is the person inquiring
Relationship*
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Phone

Personal Care and Support Needs
Does the person need support in the following areas?
Ambulating*
- Yes
- No
Notes
Transferring Assistance*
- Yes
- No
Notes
Communication*
- Yes
- No
Notes
Restroom Assistance*
- Yes
- No
Notes
Eating/Feeding*
- Yes
- No
Notes
Preferred Hospital (Name/Address)*
Medical/Takes Medications*
- Yes
- No
Notes
Seizures*
- Yes
- No
Type*
Frequency*
Notes
Other*
- Yes
- No
Notes
Does this person have a history of
- Physical Aggression
- Sexual Aggression
- Self-Harm
- Elopement
If yes to any of the above, please describe the frequency of these actions and a brief description of supports.
Alternatively, you may provide a Behavior Support Plan or Positive Action Support Plan
Does this person have a criminal background?*
- Yes
- No
Notes

Vocational Provider
Current or Recent Vocational Provider Name
If not applicable write N/A
Current Schedule
Is the person interested in employment?*
- Yes
- No
- Not Applicable
Has the person worked with Vocational Rehabilitation Services?*
- Yes, they are currently enrolled
- Yes, their file has been closed
- No

Additional Information
Any Additional Information that Would Promote Quality Services and Communication:

Please Provide Additional Paperwork to be Reviewed
As every individual has different support needs, we ask all potential intakes to send us the below information so that Opportunity Partners can make a determination of whether we believe we can provide adequate supports for the individual. You may also email these documents to referrals@opportunities.org. Failure to provide these documents may result in a delay in your application.
1. Proof of Disability: A psychological evaluation or diagnostic report (written and signed by a doctor/psychologist/psychiatrist) which states the applicant’s disabilities
2. Copy of CSSP, CSP, ISP, IEP, SPAS
3. Copy of IAPP
4. Positive Support/Behavior Plan
5. Work, school, and residential reports or other applicable evaluations
6. Any additional assessments (risk assessment)
7. Any other assessment
Upload Files
Drop files here or

Max. file size: 64 MB.
For Questions, Please Email referrals@opportunities.org
Acknowledgment and Privacy Confirmation
- I confirm that the information provided on this form is accurate to the best of my knowledge. I also acknowledge that Opportunity Partners will protect my privacy and not share the information provided.
Name
This field is for validation purposes and should be left unchanged.

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5500 Opportunity Court
Minnetonka, MN 55343

info@opportunities.org

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