Greater Expectations Program Application

Snapshot/Case History

Individual’s Name*

First Last

Gender*

Age*

Birthday*

Individual's Address*

Referred by:*

Person Completing this Form:*

Relationship to individual:*

Parent/Caregiver Phone Number*

Parent/Caregiver Email*

Who is legally responsible for the individual?*

What languages does the individual use?*

Why are you seeking these services?*

Current Diagnosis and Concerns about the Individual

Primary Diagnosis:*

Comorbid Diagnosis’:*

At what age was the diagnosis received?*

From Whom and Where was the diagnosis received?*

Please check all that apply:*

If Other, please list*

Current Living Situation

With whom does the individual currently reside? (please mark all that apply)*

If Other, please list*

Medical History

Has the individual ever had:*

Head injury
Loss of consciousness(LOC)
Allergies to food/medications
Surgery

Please describe the head injury and age of individual*

Please list age and length of loss of consciousness*

Please list all allergies*

Please list all surgeries, the reason, and the age of the individual

Please list all surgeries, the reason, and the age of the individual*

Doctors seen now or in the past*

Medication History

Please list the Name, Dose, Frequency, Date Started, Reason, and Effectiveness of all current medications*

Who prescribes these medications?*

Date of last visit:*

Please also list any medications the individual has been on in the PAST:*

Family History

Have any members of the biological mother’s or biological father’s families had any of the following problems or disorders (check all that apply):*

School History

Individual’s Highest Level of Education*

Please list all of the schools, including college or community college, the individual has attended:*

Work History

Is the individual currently employed?*

Job Title:*

Employed since:*

#of hours per week:*

Previous Employer(s). Please list: Job Tasks, Dates, and # of hours worked a week*

Services

Are you currently receiving services from anyone/anywhere (i.e. counseling, speech/OT, day programs, etc.)?*

Please list from whom, the type of service, location, and frequency*

What services, interventions, and/or supports have been lasting and meaningful?*

What services, interventions, and/or supports have NOT been lasting and meaningful?*

Funding

Are you currently receiving any state funding (i.e. SSI, HCBS, disability, etc.)?*

Additional Information:

Once submitted, you will receive a Thank You message to confirm your application was submitted correctly. If you do not receive this message, please double-check and make sure you have completed all fields.

Comments

This field is for validation purposes and should be left unchanged.

Application Process

Application/Snapshot Forms

Online Application