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Free Rem Iowa Service Application Template

The REM Iowa Service Application form is a crucial document designed for individuals seeking support services related to intellectual disabilities, developmental disabilities, and mental health. This form collects essential information about the applicant, including their personal details, service needs, and any relevant medical history. Completing this form accurately is vital to ensure appropriate services are provided.

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Free Rem Iowa Service Application Template

Table of Contents

Download Rem Iowa Service Application PDF

Things You Should Know About This Form

What is the purpose of the Rem Iowa Service Application form?

The Rem Iowa Service Application form is designed to gather essential information about individuals seeking services related to intellectual disabilities, developmental disabilities, or mental health issues. This information helps determine eligibility for various services, including residential, in-home, and community-based support.

How can I submit the completed application?

You can submit the completed application form by mailing it to REM Iowa or emailing it to their designated referral email address. For the most current contact information, please check their official website at www.remiowa.com .

What information do I need to provide about the applicant?

Applicants must provide detailed information, including:

Full name and contact information
Date of birth and gender
Diagnosis and medical history
Legal guardianship status
Financial information, including any assistance received

This comprehensive data ensures that the services offered meet the specific needs of the individual.

What types of services can be requested through this application?

The application allows individuals to request various services, including:

ICF/ID (Intermediate Care Facility for Individuals with Intellectual Disabilities)
24-hour Waiver Services
24-hour Habilitation
Host Home services
Day Habilitation

Applicants can specify their preferred communities for these services, helping to tailor support to their needs.

What if the applicant has a history of legal issues?

If the applicant has a history of arrests or legal issues, this information must be disclosed in the application. This includes any current court commitments, accusations, or convictions. Understanding the applicant's legal background is crucial for assessing their needs and ensuring appropriate support and safety measures.

Is there a deadline for submitting the application?

While there is no strict deadline for submitting the application, it is advisable to complete it as soon as possible to facilitate timely access to services. Indicating the urgency of placement, such as if it is in jeopardy, can help prioritize the application process.

What documentation should accompany the application?

To support the application, it is beneficial to attach relevant documents, such as:

Most recent psychological evaluations
Education and vocational reports
Progress reports or plans of care
Medical examination records

These documents can provide additional context and assist in determining eligibility for services.

Who can assist in filling out the application?

Family members, case managers, or care coordinators can assist in completing the application. It is essential that the information provided is accurate and comprehensive to ensure the best possible outcomes for the applicant.

Form Features

Fact Name	Fact Description
Purpose of the Form	The REM Iowa Service Application form is designed to collect necessary information for individuals seeking ID/DD/MH services.
Governing Laws	This form operates under Iowa Code Chapter 225C, which governs services for individuals with intellectual and developmental disabilities.
Application Date	Applicants must provide the date of application to track the service request timeline.
Referral Sources	The form allows applicants to specify how they learned about REM Iowa services, including options like family, friends, and advertisements.
Desired Placement	Applicants indicate their desired placement timeframe, such as "Next Available," "Within six months," or "Within one year."
Legal Guardianship	The form requires information on the applicant's guardianship status, including whether a guardian is present and their relationship to the applicant.
Health Information	Applicants must disclose current medications, physical disabilities, and any medical history relevant to their service needs.

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Key takeaways

When filling out the Rem Iowa Service Application form, several key points should be kept in mind to ensure a smooth and effective application process.

Accurate Information: Provide complete and accurate information about the applicant, including personal details like name, date of birth, and contact information. This helps in processing the application efficiently.
Service Selection: Clearly indicate the type of services desired. Understanding the options available, such as ICF/ID or Waiver services, will aid in selecting the most appropriate services for the applicant’s needs.
Referral Source: Specify how you learned about Rem Iowa services. This information can assist in understanding outreach effectiveness and may influence future service improvements.
Health and Medical Information: Be thorough when detailing any health or medical issues. This includes current medications and any physical disabilities, as such information is crucial for tailoring appropriate support.
Documentation: Attach any relevant documentation that may support the application. This could include psychological evaluations or medical records, which can significantly impact eligibility determinations.

Sample - 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.

Page|1 of 5

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

Similar forms

The Medicaid Application form is similar to the Rem Iowa Service Application form in that both documents collect personal information about the applicant, including their name, address, and date of birth. They also inquire about financial information and medical history, which helps determine eligibility for services. Both forms require the applicant to provide details about their current living situation and any support they may need, ensuring that the necessary assistance can be provided efficiently.

The Social Security Disability Insurance (SSDI) application shares similarities with the Rem Iowa Service Application form, particularly in how it gathers information about the applicant's medical conditions and work history. Both forms ask for details about the applicant's diagnosis and treatment history, which are essential for assessing eligibility for benefits. Additionally, both require the disclosure of any legal guardianship status, ensuring that the right person is applying on behalf of the applicant if necessary.

The Supplemental Nutrition Assistance Program (SNAP) application also parallels the Rem Iowa Service Application form, as both require information about the applicant’s household composition and financial situation. Each form aims to determine the level of assistance the applicant may be eligible for. They both ask for details about income sources and expenses, helping to assess the applicant's need for support in different areas of their life.

For those navigating the rental process, it's also important to consider the PDF Templates that provide essential forms, such as the Lease Agreement, to clarify terms and conditions between landlords and tenants, thereby promoting a clear understanding of responsibilities and rights related to property rental.

The Individualized Education Program (IEP) form is similar in that it focuses on the needs of individuals with disabilities. Like the Rem Iowa Service Application form, the IEP gathers information on the applicant’s educational history and current needs. Both documents emphasize the importance of tailored support services, ensuring that individuals receive the necessary resources to succeed in their respective environments.

The Long-Term Care (LTC) application shares common elements with the Rem Iowa Service Application form, particularly in the way it assesses the need for ongoing care. Both forms collect detailed information about the applicant’s medical history, including diagnoses and treatment plans. They also require information about the applicant’s daily living activities, which is crucial for determining the level of care required.

The Mental Health Service Application is another document that resembles the Rem Iowa Service Application form. Both forms focus on the applicant's mental health history and current needs. They require details about any previous treatments, medications, and support systems in place. This information is vital for ensuring that individuals receive appropriate mental health services tailored to their unique situations.

The Home and Community-Based Services (HCBS) application is similar in that it seeks to determine eligibility for community-based support. Like the Rem Iowa Service Application form, it collects information about the applicant's living situation, support needs, and financial resources. Both documents aim to facilitate access to services that allow individuals to remain in their communities while receiving the necessary assistance.

The Veterans Affairs (VA) benefits application is comparable to the Rem Iowa Service Application form in how it gathers personal and medical information. Both forms require details about the applicant's service history, health conditions, and any existing support systems. This information is crucial for evaluating eligibility for benefits and ensuring that veterans receive the care they need.

The Rehabilitation Services Administration (RSA) application also shares similarities with the Rem Iowa Service Application form, particularly in the way it assesses the needs of individuals with disabilities. Both forms gather information about the applicant’s educational and vocational history, as well as their current challenges. This data is essential for determining the appropriate support and services needed for successful rehabilitation.

Finally, the Family Support Program application aligns closely with the Rem Iowa Service Application form. Both documents collect information about the applicant's family dynamics, support needs, and financial situation. They focus on ensuring that families receive the necessary resources to support their loved ones with disabilities, highlighting the importance of a comprehensive approach to care and assistance.