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The REM Iowa Service Application form is a comprehensive document designed for individuals seeking ID/DD/MH services from REM Iowa Community Services and REM Iowa Developmental Services. It gathers detailed information about the applicant, including personal data, desired services, financial responsibility, health and medical information, and history of services. To facilitate a smooth and efficient application process for services tailored to the needs of individuals with intellectual disabilities, mental health issues, or autism spectrum disorders, interested parties are encouraged to fill out the form thoughtfully.

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The REM Iowa Service Application form encompasses a comprehensive approach to gathering vital information from applicants desiring ID/DD/MH services, emphasizing the significance of thorough data collection in orchestrating effective care and support. It initiates with a detailed inquiry about the referral pathway, capturing how applicants or their guardians became aware of REM Iowa's services, thereby illuminating the organization's reach and the effectiveness of its communication channels. Applicant information requests delve into personal, diagnostic, and legal guardianship details, ensuring a personalized and legally supported service plan. Financial responsibility, alongside desired services, paints a picture of the applicant's economic environment and their expectations from REM Iowa, which aids in tailor-making the support provided. Moreover, the form meticulously documents the history of services, referral history, and family information, allowing for a holistic understanding of the applicant's background and current needs. It doesn't stop at the surface; detailed inquiries into the applicant's financial, health, and medical information, along with a behavior skill checklist and leisure activities, underline the importance of a comprehensive service plan that catulates to the physical, mental, and social dimensions of an applicant's well-being. Conclusively, the document underscores the confidentiality and ethical use of the provided information, reassuring applicants and their families of the sensitivity and respect with which their data will be handled.

Preview - Rem Iowa Service Application Form

REM IOWA COMMUNITY SERVICES & REM IOWA DEVELOPMENTAL SERVICES

SERVICE APPLICATION FORM FOR ID/DD/MH SERVICES

Date of Application:

REFERRAL TO REM IOWA

How did you become aware of REM Iowa services?

Family | Friend

REM Iowa website

The MENTOR Network website

Hospital

REM Employee

Other Provider

Case Manager | Care Coordinator

Other

If other, please document from whom/where:

APPLICANT INFORMATION

Applicant’s Full Name:

When Desired:

Placement in Jeopardy

Next Available

Within six months

Within one year

If placement in jeopardy, indicate the date of discharge:

Current Address:

Telephone Number:

Birth Date:

Gender:

Male

Female

Height:

Weight:

lbs.

Primary Diagnosis:

Intellectual Disability

Mental Health/Illness

Autism Spectrum:

Yes

Personality Disorder:

Yes

Schizophrenia or Schizoaffective Disorder:

Yes

Other Diagnosis:

LEGAL GUARDIANSHIP STATUS

Does this applicant have a guardian?

Yes

Name of Guardian:

Relationship:

FINANCIAL RESPONSIBILITY

Case Manager | Care Coordinator Name:

Telephone Number:

Email:

IME Determination Date:

Level of

Care:

SERVICE(S) DESIRED

Type of Services Desired:

ICF/ID

24-hour Waiver (Adult)

24-hour Habilitation

Host Home**

Communities desired:

Day Habilitation (*indicates available communities below)

Unknown

1. Children ICF/DD (ID must be primary diagnosis):

Council Bluffs Only

Adult ICF/DD (ID must be primary diagnosis):

1st Opening

Shelby

Washington

Coralville

Cedar Rapids | Marion | Hiawatha

No preference

Waiver Services:

1st Opening

Des Moines Area*

Mt. Pleasant

Atlantic

Ft. Madison

Mt. Vernon

Avoca

Harlan

Shelby

Cedar Rapids |Marion| Hiawatha*

Iowa City|Coralville*

Tipton

Clinton

Keokuk

Vinton*

Council Bluffs

Marshalltown*

Waterloo | Cedar Falls |Waverly

Davenport | Bettendorf

Mason City

No Preference

Other community (s):

**Host Home is a service where individuals live in private family homes and receive specialized assistance from a dedicated caregiver we call a Mentor.

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Revised 03.17

HISTORY OF SERVICES

Residential/ in-home services (e.g. hourly services, 24-hour waiver, ICF/ID, nursing home, etc.)

Has the applicant always lived at home?	Yes	No

Service	Provider

Dates

Day/Vocational Services
Has the applicant ever been employed:	Yes	No	At a day program?	Yes	No

Service

Provider

Dates

REFERRAL HISTORY

Has the applicant ever been arrested?

Yes

If yes, provide: Date(s):

Reason(s):

Outcomes:

Does the applicant have a current court committal?	Yes	No
Has the applicant been accused/convicted of sexual abuse?			Yes	No
If yes, provide: Date(s):
Outcomes:
Has the applicant had any history of cruelty to animals?			Yes	No
If yes, provide: Date(s):
Outcomes:
Has the applicant attempted suicide or had suicidal ideations?			Yes	No
If yes, provide: Date(s):
Outcomes:
Has the applicant had any history of fire setting?			Yes	No
If yes, provide: Date(s):
Outcomes:
Has the applicant had any history of cutting self, swallowing or insertion of foreign objects or			Yes	No
strangulation?
If yes, provide: Date(s):
Outcomes:
Has the applicant had physical aggression that required physical, mechanical or chemical restraint
via injection over the past 12 months?			Yes	No

Page|2 of 5

Revised 03.17

FAMILY INFORMATION

Mother’s Name (first & last):

Address:

Home Telephone #:

Work Telephone #:

Email Address:

Father’s Name (first & last):

Address:

Home Telephone #:

Work Telephone #:

Email Address:

Sibling’s Full Name(s) (first & last):

Significant Other Name (first & last):

Address:

Home Telephone #:

Work Telephone #:

Email Address:

APPLICANT’S FINANCIAL INFORMATION

Receive Financial Assistance:

Yes

If yes, type:

SS (Social Security)

SSI (Supplemental Social Insurance)

If other, document type:

VA (Veteran’s Benefits)

Child Support

Adoption Subsidy

Other

Does applicant have Title 19?

Yes

Managed Care Organization (MCO)?

Amerihealth Caritas

Amerigroup

United Health

Optum N/A

Does applicant have Waiver funding?

Yes

Does applicant have Habilitation funding?

Yes

Does applicant have private insurance?

Yes

Does applicant have other income (trust fund, etc.)?

Yes

APPLICANT’S HEALTH/MEDICAL INFORMATION

Current Medication(s) or can attach current medication orders or record:

Name	Dose	Frequency	Reason for Taking

Prescribed By

Page|3 of 5

Revised 03.17

Physical disabilities that require the use of adaptations (e.g. AFOs {braces}, orthopedic shoes, cane, walker, wheelchair,

etc.)	Yes	No
If yes, list adaptive equipment:
Seizures:	Yes	No	History of
If yes or history of, describe type and frequency:
Vision Problems:		No	Yes – correctable with glasses		Yes – but chooses not to wear glasses
		Yes - uncorrected		Blind Comments:
Hearing Problems:		No	Yes – correctable with hearing aides		Yes – but chooses not to wear hearing aides
		Adapt by others speaking louder			Deaf

Comments:

Skill Checklist: (please check items which best describe applicant)

BEHAVIOR	Consistently Sometimes Never Comments
Becomes upset when
redirected/corrected
Demands excessive
attention from others
Complains of being
persecuted
Pretends to be ill
Changes mood without reason
Bosses or manipulates others
Hyperactive
Hoards things
PICA (eats inedible objects) (if
displays, list items in
comments)
Self stimulation
Self injurious behavior
Verbally aggressive
Physically aggressive toward
others
Physcially aggressive toward
objects
Displays sexually inapprorpriate
behavior
Removes clothing in public
Tears clothing
Steals other's belongings
Elopes / runs away from home
Uses tobacco
Uses alcohol
Uses other drugs

Page|4 of 5

Revised 03.17

LEISURE ACTIVITIES

Interests:

Hobbies:

Dislikes:

CLOSING

The information we have asked you to provide is necessary for the effective administration of the services for which you are applying. The information collected will only be used by authorized agency personnel. Use of this information for purposes other than expressed herein will not occur without your prior written approval, unless such other use is specifically authorized by law.

Attach any of the following materials that may be helpful in determining eligibility for service:

Most recent psychological evaluation

Most recent education and/or vocational report

Most recent progress reports or plan of care

Physical and/or specialty medical examinations

Other Documentation that you feel would be helpful


Completed by:
Applicant Name:					Date:
Case Manager Name:					Date:
Parent/Guardian Name:					Date:
Name/Title:					Date:

Please return form to: REM Iowa (please check website for current contact information @ www.remiowa.com)

or send to REMIowaReferral@thementornetwork.com

Page|5 of 5

Revised 03.17

Click for Rem Iowa Service Application

File Breakdown

Fact	Detail
Form Name	REM Iowa Service Application Form for ID/DD/MH Services
Revision Date	March 2017
Types of Services Covered	ICF/ID, 24-hour Waiver (Adult), 24-hour Habilitation, Host Home
Programs Available for	Intellectual Disability, Mental Health/Illness, Autism Spectrum, Personality Disorder, Schizophrenia or Schizoaffective Disorder.
Governing Law	Iowa State Law
Application Submission	Via email to REMIowaReferral@thementornetwork.com or through REM Iowa's website
Financial Responsibility	Details including Case Manager, IME Determination Date, and Level of Care required.
Applicant's Legal Guardianship Status	Information on whether the applicant has a guardian and the guardian's details.
Applicant's Health and Medical Information	Details on current medications, physical disabilities, seizures, vision and hearing problems.

How to Use Rem Iowa Service Application

Filling out the REM Iowa Service Application form is a detailed process that allows individuals seeking ID/DD/MH services to provide necessary information about themselves and their needs. This step-by-step guide will assist individuals, their families, or their guardians in completing the application with accuracy and ease. By sharing details about the applicant’s background, health, and desired services, REM Iowa can match the individual with the most suitable support offerings.

Start with the Date of Application section by entering the current date.
In the REFERRAL TO REM IOWA section, select how you became aware of REM Iowa services and specify further if you choose "Other".
Proceed to the APPLICANT INFORMATION section:
- Enter the Applicant’s Full Name.
- Indicate when the services are desired, and if "Placement in Jeopardy" is selected, provide the discharge date.
- Fill in the Current Address, Telephone Number, Birth Date, Gender, Height, and Weight.
- Detail the Primary Diagnosis and mark appropriate responses for Autism Spectrum, Personality Disorder, and other specific diagnoses.
In the LEGAL GUARDIANSHIP STATUS section, indicate if the applicant has a guardian and provide the name and relationship if applicable.
For the FINANCIAL RESPONSIBILITY section, complete the required fields including the Name, Telephone Number, and Email of the Case Manager or Care Coordinator, along with the IME Determination Date and Level of Care.
Select the Type of Services Desired and specify the community or communities preferred for these services.
Under HISTORY OF SERVICES, share any relevant residential, in-home, or day/vocational service history including dates and providers.
Complete the REFERRAL HISTORY part by answering questions related to arrest history, court commitments, or other behavioral tendencies and provide details as necessary.
Proceed to the FAMILY INFORMATION section by providing details about the mother, father, siblings, and significant other, including names, addresses, telephone numbers, and email addresses.
In the APPLICANT'S FINANCIAL INFORMATION section, disclose any financial assistance, managed care organization affiliation, waiver funding, and other income details.
Detail the APPLICANT'S HEALTH/MEDICAL INFORMATION by listing current medications, physical disabilities requiring adaptations, seizure history, vision and hearing problems, and complete the skill checklist focusing on behavior and leisure activities.
Review the closing statement understanding the use and confidentiality of the information provided. Attach any additional documentation that would aid in the application process.
Fill in the completion section with the Applicant Name, Date, Case Manager Name, Date, Parent/Guardian Name, Date, and the Name/Title of the person completing the form with the date.
Send the completed form to REM Iowa as directed on the form.

By following these steps carefully, the application will be properly prepared for submission. This ensures that all necessary information is conveyed in an organized manner, facilitating a smoother evaluation process for services desired.

Key Details about Rem Iowa Service Application

What types of services does REM Iowa offer?

REM Iowa provides a broad spectrum of services for individuals with Intellectual Disabilities (ID), Developmental Disabilities (DD), and Mental Health (MH) issues. These services include, but are not limited to, Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/ID), 24-hour waiver services for adults, 24-hour habilitation, host home opportunities, and day habilitation. These services are tailored to meet the diverse needs and preferences of each applicant, aiming to support their development and integration into the community.

How can someone apply for services from REM Iowa?

To apply for services from REM Iowa, an individual or their guardian must complete the REM Iowa Service Application Form. This detailed form collects information on the applicant's personal details, diagnosis, legal guardianship status, financial information, desired services, history of services, referral history, family information, and health/medical information. Once completed, the form should be returned to REM Iowa as directed on the application, either through the website or by emailing REMIowaReferral@thementornetwork.com.

Is there financial assistance available for services?

Yes, applicants may receive financial assistance for services through various sources such as Social Security (SS), Supplemental Security Insurance (SSI), Veterans Benefits (VA), child support, adoption subsidy, Title 19, managed care organizations, waiver funding, habilitation funding, private insurance, or other income such as trust funds. During the application process, individuals are asked to specify their sources of financial assistance to help determine eligibility and the extent of financial coverage for services.

What information is required about the applicant's health and medical condition?

The REM Iowa Service Application Form requests comprehensive information on the applicant's health and medical condition. This includes current medications, physical disabilities requiring the use of adaptive equipment, seizure history, vision and hearing problems, and a detailed behavior and skills checklist. Applicants can also attach current medication orders or a record, along with any recent psychological evaluations, medical reports, and other documents that can aid in assessing their needs and eligibility for services.

Who is eligible for REM Iowa's services?

Eligibility for REM Iowa's services is determined based on a variety of factors including, but not limited to, the applicant's diagnosis of Intellectual Disability, Developmental Disability, or Mental Health issues, their legal guardianship status, financial responsibility, and specific service needs. REM Iowa aims to cater to a wide range of individuals with varying needs, offering services designed to support their development, well-being, and community integration.

Can family members be involved in the application process?

Family members are encouraged to be involved in the application process and can assist in completing the application form. The form requests information on family details, and family members can provide valuable insight into the applicant's history, needs, and preferences. REM Iowa also recognizes the importance of family involvement in the ongoing provision of care and support services.

Is there a deadline for the application?

While there's no specific deadline mentioned for submitting the REM Iowa Service Application Form, it's advisable to submit the application as soon as possible, especially if the placement is in jeopardy or there's a specific desired timeframe for service commencement. Timely submission ensures that the application can be processed and that appropriate services can be arranged to meet the applicant's needs.

Common mistakes

Filling out the REM Iowa Service Application form accurately is crucial for accessing the right services. However, mistakes can happen. Here are some common errors to avoid:

Not specifying how they became aware of REM Iowa services. It's important to fill out this section completely to help REM Iowa understand how applicants are finding their services.
Omitting the desired time frame for placement. This information helps REM Iowa plan for the applicant's arrival and prioritize applications appropriately.
Incomplete legal guardianship status information. If the applicant has a legal guardian, this section must be filled out fully to ensure all legal and care decisions are properly managed.
Skipping the financial responsibility section. Detailing who is financially responsible and including contact information is critical for billing and service eligibility purposes.
Leaving the section on desired services blank or incomplete. Applicants need to clearly indicate the type of services they require to ensure they are matched with appropriate support.
Failing to provide a complete medical and behavioural history. Accurate history is essential for REM Iowa to provide tailored and safe care.
Omitting details about current medications or existing physical conditions. This information is crucial for day-to-day care and medical safety.
Not attaching necessary supplementary documents. Reports such as psychological evaluations and progress reports are vital for a comprehensive understanding of the applicant's needs.

By avoiding these mistakes, applicants can ensure their form is correctly filled, which is crucial for them to access the appropriate services and support from REM Iowa.

Documents used along the form

When submitting the REM Iowa Service Application form for ID/DD/MH services, various forms and documents often accompany the application to provide a comprehensive overview of the applicant's needs, history, and eligibility. These additional documents help ensure that the applicant receives the most appropriate and effective services. They range from medical evaluations to financial information, each playing a crucial role in the application process.

Most recent psychological evaluation: This document provides insight into the applicant's mental health status, including diagnoses, cognitive abilities, and recommendations for care. It is crucial for understanding the individual's needs and tailoring services accordingly.
Most recent education and/or vocational report: This report outlines the applicant's educational or vocational history and current status, helping service providers adapt programs to fit the applicant's learning and development levels.
Most recent progress reports or plan of care: These reports from previous or current service providers detail the applicant's progress in various areas, helping to inform the development of a new, personalized plan of care.
Physical and/or specialty medical examinations: Medical assessments provide essential information on the applicant's physical health, including any conditions that might affect the type of care or services needed.
Proof of Legal Guardianship: If applicable, a document verifying legal guardianship is necessary to confirm the guardian's authority to make decisions on behalf of the applicant.
Financial Documentation: Evidence of financial resources, such as Social Security, SSI, or other benefits, helps in determining the applicant's eligibility for certain services and supports.
Insurance Information: Details of any private insurance, Managed Care Organization (MCO) affiliation, or other coverage help in coordinating payment for services and identifying what benefits the applicant may have.

Together, these documents supplement the REM Iowa Service Application form, providing a full picture of the applicant's situation. This comprehensive approach ensures that the services provided can be as effective as possible, tailored to meet the unique needs of each individual. It's essential for applicants or their guardians to gather and provide this information to facilitate a smooth application process and aid service providers in delivering optimal care.

Similar forms

The Rem Iowa Service Application form, designed for individuals seeking ID/DD/MH services, shares similarities with a range of other forms and applications used within social service and healthcare systems. One exemplary form is the Medicaid Application form. Like the Rem Iowa form, the Medicaid Application form collects detailed personal, financial, and health information to assess eligibility and tailor services to the applicant's needs. Both forms require information on diagnoses, financial status, and existing healthcare coverage, ensuring that individuals receive the most appropriate support according to their specific situations.

Another similar document is the Vocational Rehabilitation Services Application. This form, used by individuals seeking assistance with employment due to a disability, gathers detailed information about the applicant's health condition, work history, and the type of support needed. Similar to the Rem Iowa Service Application, it emphasizes the importance of understanding the applicant's unique challenges and goals to provide customized services that enhance their ability to engage in meaningful employment or activity.

The Supplemental Security Income (SSI) Application also mirrors the Rem Iowa form in its purpose and content. It meticulously collects information about the applicant's financial situation, health status, and living arrangement to determine eligibility for financial assistance. Both forms assess the need for financial support by analyzing the individual's income, healthcare needs, and disability status, demonstrating a focused approach to identifying and addressing the specific needs of those with disabilities.

Additionally, the Application for Community-Based Services shares a common goal with the Rem Iowa form, focusing on connecting individuals with community services that support their living and health conditions. This form collects detailed information about the applicant's preferences, health status, and desired services, similar to how the Rem Iowa Service Application identifies suitable residential or habilitation services for individuals with ID/DD/MH needs. Both applications serve as critical tools for aligning services with the specific needs and preferences of the applicant, ensuring a personalized approach to care and support.

Lastly, the Housing Assistance Application form is another document that exhibits similarities to the Rem Iowa Service Application. Both forms play a crucial role in ensuring that individuals with specific needs, such as those with disabilities or mental health issues, gain access to suitable housing or living arrangements. The Housing Assistance Application, like the Rem Iowa form, requires detailed personal and financial information, along with a comprehensive assessment of the individual's situation, to connect them with appropriate housing solutions that accommodate their needs and promote their well-being.

Dos and Don'ts

When filling out the REM Iowa Service Application form, there are essential do's and don'ts that applicants and their guardians should follow to ensure the process is smooth and the information provided is accurate and comprehensive.

Do's:

Ensure that all the required fields have been filled out accurately. Missing information can delay the application process.
Provide detailed information about the applicant’s diagnosis and health/medical information. This includes current medications, physical disabilities, and any need for adaptive equipment.
Include comprehensive historical data related to services previously or currently being utilized, as well as the applicant's behavioral patterns and leisure activities. This information helps REM Iowa tailor their services to the applicant's needs.
Attach any additional documentation that may support the application. This could include psychological evaluations, educational reports, progress reports, or plans of care. These documents provide a more detailed understanding of the applicant's needs and capabilities.
Review the application thoroughly before submitting. Double-check for any errors or omissions that could affect the processing of the application.

Don'ts:

Don't leave sections incomplete. If a section does not apply, it is better to indicate this with "N/A" (Not Applicable) rather than leaving it blank.
Avoid providing vague or unclear answers. Be as specific and detailed as possible to ensure an accurate assessment of the applicant’s needs.
Do not guess information about diagnoses, treatments, or behavioral patterns. If unsure, it’s advisable to consult with a healthcare provider or case manager for accurate details.
Do not omit any history of behavioral challenges, legal issues, or medical conditions, as these are crucial for designing an appropriate care plan.
Refrain from submitting the application without the consent and review of the legal guardian (if applicable). Their signature and input may be necessary for legal and procedural reasons.

Misconceptions

There are several misconceptions about the REM Iowa Service Application form. Understanding these can help applicants provide accurate information and set realistic expectations for the services they are seeking. Here, we address four common misconceptions.

Misconception #1: The service application form strictly caters to adults.
While the form does provide options for adult services, it's crucial to note that REM Iowa also offers services for children, specifically in the Children ICF/DD option listed under the types of services desired. This ensures support for individuals across a broad age range.
Misconception #2: Legal guardianship status is optional.
It might seem like filling out the legal guardianship section of the application is optional, but this information is vital. Whether or not the applicant has a guardian affects the application process and the type of services they may be eligible for.
Misconception #3: Financial responsibility details are only about the applicant.
The section on financial responsibility isn't just about whether the applicant receives financial assistance; it's also meant to detail who is financially responsible for their care. This includes information on the case manager or care coordinator, showcasing the need for a comprehensive understanding of the applicant's financial support system.
Misconception #4: Health/medical information is secondary.
Some might underestimate the importance of the health/medical information section. However, this portion of the form is critical. It helps REM Iowa understand the applicant’s medical needs, ensuring they match with suitable services. For instance, details about seizures, vision or hearing problems, or physical disabilities impact service provision significantly.

Understanding these aspects thoroughly can assist in aligning expectations and in submitting a well-informed application to REM Iowa.

Key takeaways

When completing and utilizing the REM Iowa Service Application form for ID/DD/MH services, several key takeaways should be considered. These insights help streamline the process, ensuring that applicants or their guardians provide the necessary and correct information required for a successful application.

Being informed about how one became aware of REM Iowa services is the first step, which could range from family and friends to hospital referrals or online sources.
When filling out applicant information, ensuring accuracy in details like the full name, desired placement timing, and current address is crucial. It's also important to specify if the placement is in jeopardy and the urgency of the service needed.
The form requires documentation of the applicant's primary diagnosis and other potential diagnoses, which helps REM Iowa tailor the services appropriately to the individual's needs.
Legal guardianship status must be clearly indicated; if the applicant has a guardian, their name and relationship to the applicant need to be provided.
Financial responsibility, including the case manager's contact information and specifics regarding any IME determination, is necessary to ensure the appropriate level of care and service.
The section on the type of services desired allows applicants or guardians to express preferences regarding residential and day habilitation services, making it important to consider and indicate the most suitable options.
Past history of services, referral history, and any behavioral information provide REM Iowa with valuable insights into the applicant's needs and how best to support them.
Completing the family information thoroughly will assist REM Iowa in understanding the applicant's support system, which can play a significant role in their care.
Details about the applicant's financial information, health/medical information, behavioral tendencies, and leisure activities should be filled out accurately to help the agency in planning and implementing personalized services.

In conclusion, the REM Iowa Service Application form is a comprehensive document designed to capture essential information about the applicant. This information ensures that the services provided are tailored to meet the unique needs of each individual, facilitating a smoother integration into the programs offered by REM Iowa. Proper completion of this form is the first step toward accessing the necessary support and services for individuals with ID/DD/MH conditions in Iowa.

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