Admission Form

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APPLY FOR ADMISSION


With innovative therapy and compassionate care, we’ll help you find balance…for family, for community, for life.


Before starting the application, it will be helpful to have the following documents ready to upload. (This information may also be forwarded to us at a later time).

·       A psychological evaluation stating an autism spectrum diagnosis (conducted by a licensed psychologist or developmental pediatrician)

·       The most recent interdisciplinary team annual review (IEP, ISP, IPP, etc)

·       SIS (Supports Intensity Score) Evaluation (adults only)

·       Medicaid and/or insurance information 


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Applicant Information



Current Services Received





Applicant Address




Referral Information















Guardian Information




Guardian Address






Guardian 2




Guardian Address





Services

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Service Information


Adult Service 1
Support provided for individuals while living in the home of a parent/guardian



Please hold the CTRL key to select more than one time of service from this list.
Adult Service 2
Residential services for adults in one of six four-bedroom homes at our Pleasant Hill location, 20 miles east of Des Moines, for ages 18 and older; licensed as as ICF/ID facility.


Adult Service 3
Home and Community Based living for adults receiving support around the clock, age 18 and older, living in a provider-owned home (participants in this program are matched with up to three roommates also requiring supported community living).


Adult Service 4
Employment services offers a continuum of services ranging from structured learning to community based job coaching and support. Individuals will receive a personalized plan of support based on their unique strengths and supports required, with the overall goal of gaining the skills necessary for obtaining meaningful paid work.


Adult Service 5
Support is provided to individuals, age 18 and older, who live alone and only need a few hours per day of support.



. Please hold the CTRL key to select more than one time of service from this list.

Children Service 1
ABA (Applied Behavior Analysis) Support for children in our autism clinic setting for children (diagnosis) up to age 18; sessions are held for up to five days a week for 2 1/2 - 3 hours per day. This service also includes individualized support and programming to reduce the impant of any deficit or problem areas that impact the adolescent's life and growth.





Please hold the CTRL key to select more than one time of service from this list.
Children Service 2
Balance Autism Hang Out Camp is a social skills group that meets across multiple days in a 1 - 2 week period, which allows for targeting social skills to be intesively taught and practiced (i.e. spring break, winter break or summer). Social Skills Group meets one day a week for two consecutive months, which allows for follow-up instruction to maintain skills learned at camp, and to build deepr friendships based on interests.




Children Service 3
Support provided for individuals while living in the home of a parent/guardian



Please hold the CTRL key to select more than one time of service from this list.
Children Service 4
Residential Service for Children in Altoona, Iowa, for ages 5 – 18 years old; licensed as ICF/ID facility.


Children Service 5
When families live beyond 100 mile of our office locations, we equip parents/guardians with technical skills to replicate the teaching strategies used by Balance Autism. This service is provided in a telehealth model, using telcommunication technologies to deliver consultation, education and instruction.


Other Services
Please provide details of the services you would like to receive in the future.





Current Agency Involvement
Please provide details of your current agency involvement.




Medical Information

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Medical Information

Yes No

If the applicant has any physical limitations, please list any adaptive devices (i.e. wheelchair, shoe inserts, braces, walkers, etc.)
Yes No

Yes No
Prescription Medication 



Yes No
Allergy Information



Please hold the CTRL key to select multiple values from this list.


Please hold the CTRL key to select multiple values from this list.

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Applicant Insurance Information













Case Manager Information








Attachments

The following items are needed to complete the applicant's file. This application might be submitted without supporting documentation. However, all remaining items must be received before an applicant will be added to our waiting list.
 

Attachments






Additional Documentation 1
If you would like to provide any additional information, please add it here.





Additional Documentation 2
If you would like to provide any additional information, please add it here.





Additional Documentation 3
If you would like to provide any additional information, please add it here.




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Please include anyone that may inquire about the applicant's application file and waiting list status.