Admissions Form - The Opportunity Tree

Welcome to The Opportunity Tree!

Thank you for your interest in our services! After you have completed a tour of one of our facilities and decided on a program(s), please complete the entirety of this application. The purpose of this application is to provide us with accurate information about the applicant. Please exercise full disclosure when filling out these forms, as they will assist us in knowing how to properly serve the applicant.

As an organization, we have experience working with the unique needs and circumstances of our Members. Knowing specific health care needs, behaviors, coping mechanisms, and triggers of the applicant will greatly help us in providing the most beneficial and positive supports possible.

Thorough completion is imperative to the proper placement of the applicant.

Please email the following documents to info@theopportunitytree.org after submitting this form:

1. Copies of State ID, Driver’s License, Birth Certificate or Passport
2. Guardianship Papers (if applicable)
3. Health Insurance Card
4. Copy of any professional evaluations or assessments
5. Current ISP or IEP
6. Employment Services only:
a. Copy of Social Security Card
b. Completed Arizona and Federal Tax forms

Once this form has been submitted to a service coordinator or program manager, we will contact you to set up a pre-placement meeting. After reviewing information from the application and the tour, the Intake Committee will decide the eligibility or placement of the applicant. The outcome of this process will result in: placement in the program applied for, placement on a waiting list or an alternate referral plan.

We encourage you to contact your local service coordinator at any point during this process if you have any questions or concerns. The Opportunity Tree is here to help you navigate this process from start to finish.

Thank you for your interest in The Opportunity Tree, we’re excited to get started!

Questions? Email us at info@theopportunitytree.org or call at 602-956-0400.

Equal Opportunity Employer

The Opportunity Tree recognizes the value of using human resources to their fullest and declares through its bylaws and policies that it will afford equal opportunity to all individuals regardless of race, color, religion, sex, or national origin. In compliance with the American with Disabilities Act makes reasonable accommodations to persons with disabilities to participate in the agency’s programs, settings, and activities.

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Name

First

Last

Main Contact

First

Last

Relationship

Date of birth

Phone

Street address

Primary Diagnoses:

Secondary Diagnoses:

Name of school (if still a student):

How did you hear about us?

Campus of interest

Funding Source

Programs/Services of interest

Name of A.M. transportation

A.M. transportation phone number

P.M. transportation name

P.M. transportation phone number

Emergency Contact 1

Emergency Contact 1 relationship

Emergency Contact 1 home phone

Emergency Contact 1 work phone

Emergency Contact 2

Emergency Contact 2 home phone

Emergency Contact 2 work phone

Emergency Contact 3

Emergency Contact 3 home phone

Emergency Contact 3 work phone

Guardian information

If you are your own guardian, you may skip the next questions about guardian information.

Guardian name

Guardian relationship

Guardian street address

Guardian city

Guardian state

Guardian zip code

Guardian email

Guardian primary phone

Family information

Family name(s)

Family relationship

Family street address

Family city

Family state

Family zip code

Family email

Family phone

Additional Relevant Diagnosis/ Medical Needs

Applicant height

Applicant weight

Chronic or Reoccurring Medical Conditions:

Insurance company

Insurance policy number

Secondary insurance

This field is optional.

Secondary insurance policy number

This field is optional.

Special Health-Related Instructions:

Mobility

Walks with Assistance with:

If applicant walks with assistance, please describe their mobility needs here:

Special Dietary Requirements:

Allergies (Foods, Medications):

Fine motor impairments:

Include options for assistance (hand over hand, modified utensils, etc)

Eating & Drinking Practices:

If eating Requires Assistance and/or Supervision and/or With Adaptive Equipment, please describe:

Toileting & Menstrual Care:

If Member requires assistance with toileting & menstrual care, please describe:

Perscription medications

Please provide the following: Medication name, Medication time administered, and dosage.

Applicant date of birth

Applicant street address

Applicant city

Applicant state

Applicant phone number

Race

All demographic data submitted statistically. Individual confidentiality shall be maintained for our Members.

Ethnicity

All demographic data submitted statistically. Individual confidentiality shall be maintained for our Members.

Disability - Primary Diagnosis

Disability - Secondary Diagnosis

Household - type of residential setting:

Total number of individuals living in household

This includes the Member.

Does the applicant clearly communicate their wants and needs?

Which most accurately describes the applicant’s speech?

What form of communication is the easiest way for the applicant to express themselves to others?

What form of communication makes it easiest for the applicant to understand others?

Are there any considerations that we should make when communicating with the applicant?

Does the applicant currently receive any therapies? If so, please briefly describe their current goals so we can help provide consistent standards for the applicant’s communication while they’re in program.

Does the applicant have any history of seizures?

Has the applicant had any seizure activity in the past 5 years?

When (month/year) was the last seizure?

How frequently does the applicant have seizures (times per day, week, month, or year)?

How long can a seizure last before medical intervention becomes necessary?

Describe any antecedents to a seizure:

Are the seizures currently being controlled with medication?

Is there any noticeable change in behavior after a seizure (e.g. groggy, confused, irritable, etc)?

How does a seizure typically present itself? Please describe the physical characteristics, and the typical duration:

Describe medical interventions that are appropriate and available in an emergency (nerve stimulator, medication, length of seizure before calling paramedics, etc.).

Please discuss any other information relating to seizures that is important for the individual’s safety?

Does the applicant exhibit age appropriate social skills?

If no, please describe the behavior that is not age appropriate:

If yes to any of the above, please describe the context of the behavior, including when the last instance was, possible causes of the behavior, and effective techniques to resolve the situation. Feel free to include additional pieces of paper to give the most detailed information possible.

If any of these behaviors have caused a concern for the safety of the applicant or other people, is anything currently being done to manage the behavior? This might include a formally implemented Behavior Treatment Plan, an approach to handling stress, therapy, or avoiding particular triggers for the behavior

Does the applicant have any behaviors that come before the harmful behavior? What warning signs are exhibited by the applicant that would help us deescalate the situation before it becomes unsafe?

Check the option that you feel is most accurate:

What sort of environment does the applicant prefer most of the time?

Does the applicant have any sensitivity to light, sound, touch or other sensory perceptions that we might consider in order to create a positive and comfortable environment for them?

What are some activities that the applicant enjoys, or that they might enjoy if given the opportunity? This might include participation in arts programs (like painting, photography, or theatre), regular physical exercise, volunteering in the community, or something that they’ve expressed interest in the past. Please be as specific as possible.

Can the applicant identify the current day of the week?

Can the applicant identify the current day of the year?

Can the applicant tell time on a digital clock?

Can the applicant tell time on an analog clock?

What is the highest number the applicant can count to without assistance?

What is the applicant’s current math comprehension?

Completes basic addition and subtraction problems
Completes basic multiplication and division problems
Math skills are equivalent to a freshman in high school
Math skills are equivalent to a high school graduate
Math skills are at a post high school level

Please check all of the following that describes the applicant’s money management skills:

Can count bills
Can count change
Understands how to make a purchase in a store using money or credit cards (may need assistance in counting the money)
Can plan a budget for at least one shopping trip

What is the applicant’s current reading comprehension?

No ability to read
Reads sight words and identifies symbols (stop signs, restroom signs, etc.)
Simple reading (around the level of a 3rd grader)
Average reading (at least middle school or junior high level)
Advanced reading (post high school level)

Which academic and life skills would be most beneficial for the applicant to spend time improving? Check all that apply:

What teaching techniques tend to be the most effective for the applicant when learning a new skill? Check all that apply:

How many instructional steps can the applicant follow at a time?

Please describe any other teaching techniques that might be effective:

Family Medical History

If a member of the family has had any of the following, check (✓) the applicable box(es).

Allergies

If the Member has a history of allergies, please explain:

Dental History

Gum Disease
Orthodontic Appliances
Other

Current Medications:

Date of Last Physical Examination:

Surgeries, Hospitalizations, Treatments, and Significant Accident Injuries:

Any allergies applicant may have:

Signs and symptoms of applicant allergy:

Steps to be taken if signs appear:

Food Preparation:

Regular
Bite-sized
Puree

Special Diet

Nutritional Supplements:

Choke or gag reflex

Assistance required during mealtimes (i.e. adapted utensils, positioning, etc.):

Please add any additional context on the applicant's food preparation and dietary needs here:

Can the resident obtain / request fluids?

If no, specify system to ensure adequate fluids are provided:

Specify medical / nutritional fluid recommendations (if applicable):

Adaptive Equipment (i.e. Glasses, hearing aids, wheelchairs, communication devices, etc.):

Facility Adaptations (i.e. Ramps, Plexiglas windows, grab bars, etc.):

List any adaptive equipment needs the applicant may have here:

Please list any special instructions for lifting, carrying, and positioning the applicant:

If yes - please specify any equipment and/or time schedules associated with lifting, carrying, and positioning the applicant.

Please list any other additional health care needs or routines the applicant may have here:

Examples include: brushing teeth, flossing, nail care, etc.

Special instructions for bathing

Please list any special instructions for bathing here:

Examples include: methods and/or products required to bathe the applicant.

Supervision required for bathing?

Staff gender preference for bathing assistance

Male
Female
None

Special lab work required for medical monitoring?

(i.e. Lithium levels, Dilantin levels, thyroid, etc.)

If yes, please specify here:

Please specify the types of lab work that are required for the applicant's medical monitoring, as well as the frequency with which these tests are needed.

Does the applicant take a seizure medication?

Are seizures documented?

If yes, please specify here:

Does the applicant take a blood pressure medication?

Are the parameters for this medication established by a physician?

If yes, what monitoring techniques are used?

(i.e. frequency, ranges, etc.):

If blood pressure is out of established ranges, what procedures should be implemented:

Applicant is diabetic

If yes, please specify the frequency of blood sugar levels being recorded:

If yes, please specify the parameters established by a physician:

Our Locations

Phoenix

3146 E. Windsor Ave.

Phoenix, AZ 85008

Casa Grande

209 W. 1st St.

Casa Grande, AZ 85122

Avondale

328 W. Western Ave.

Avondale, AZ 85323

Maricopa

19756 North Maricopa Rd.

Suites #108 & 109

Maricopa, AZ 85139

Campus Hours:

Monday – Friday – 8 AM – 6 PM

The Opportunity Tree is closed on federal holidays.

Get in touch:

Phone: (602) 956-0400

info@theopportunitytree.org

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