Childrens hospital trachbook

7/21/2019 Childrens hospital trachbook

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FAMILY DEMOGRAPHICS

Home Address:

Home phone: Alt phone/cell: Relationship:

Legal Guardian:

Primary language spoken: Interpreter needed: Yes, No

Patient’s parents/guardians status: Single / Married / Separated / Divorced / Living w partner / Widowed /

Other

Primary Family Members

Full Name:

Resides w/

patient?

Age or DOB Relationship to patient

a. Y/N

b. Y/N

c. Y/N

d. Y/N

e. Y/N

f. Y/N

g. Y/N

EXTENDED SUPPORTS

Name: Relation: Contact Info:

Availability / Type of Support:


Avilability / Type of Support:









$'

PROVIDERS

Medical Specialists

Name/Specialty:

Contact Info:

Name/Specialty:

Contact Info:

Name/Specialty:

Contact Info:

Name/Specialty:

Contact Info:

Name/Specialty:

Contact Info:

Name/Specialty:

Contact Info:

Name/Specialty:

Contact Info:

Name/Specialty:

Contact Info:

Therapists

OTProvider/Therapist:

Fequency / Contact Info:

Provider/Therapist:


PT

Provider/Therapist:


Provider/Therapist:


ST

Provider/Therapist:


Provider/Therapist:


Home Care

Agency / Supervisor :

Contact Info:

Funding Source:

Skilled Visits (frequency):

Private Duty (hours):

Aide:

Agency / Supervisor :

Contact Info:

Funding Source:

Skilled Visits (frequency):

Private Duty (hours):

Aide:

DME

Provider :

Equipment:

Contact Info:

Provider :

Equipment:

Contact Info:

Provider :

Equipment:

Contact Info:

Provider :

Equipment:

Contact Info:



$(

KUE)VRUGF

Primary:

Policy copy obtained?:

ID#:

Contact Info:

Secondary:


ID#:

Contact Info:

Medicaid:


ID#:

Contact Info:

BCMH/Title V:


ID#:

Contact Info:

Waiver type:

Services provided:

On Waiting list?:

Case Manager:

Contact Info:

PROGRAMSSchool:

Grade:

Contact Info:

IEP or 504 ?

Goals: (Therapies/Behavior/Academic)

MR/DD or EI:

Case Manager:

Contact Info:

Services provided:

Financial Benefits: TANF / Food Stamps / Child Care

Subsidy ?

ODJFS:

Protection Issues: Open Case / Foster Care / Adoption

History:

TRANSPORTATION

Methods: Family Vehicle

Public

Rides from others

Transportation Company

Other:

Considerations: Handicap Placard

Car Seat / Safety

Wheelchair lift

Stretcher

New Vehicle needed

Other:

UTILITIES / EMS

Phone:

notes –

Outstanding Bill?

Disconnection?

Priority Reconnection Letter?

Energy:

notes –

Outstanding Bill?

Disconnection?




Water :

notes –

Outstanding Bill?

Disconnection?


Local EMS:

Contact Info:

Childrens hospital trachbook

Documents

Transcript of Childrens hospital trachbook