DISABLING CONDITIONS AND BARRIERS PHYSICAL DISABILITY [All Clients] No Client doesn’t know Yes Client refused IF TO PHYSICAL DISABILITY SPECIFY “YES” – No Client doesn’t know Receiving services for physical disability Yes Client refused Is the physical disability expected to be of long-continued and No Client doesn’t know indefinite duration and substantially impairs ability to live Yes Client refused independently. Documentation of the disability and severity on file No Yes DEVELOPMENTAL DISABILITY [All Clients] No Client doesn’t know Yes Client refused IF TO DEVELOPMENTAL DISABILITY SPECIFY “YES” – No Client doesn’t know Receiving services for developmental disability Yes Client refused No Client doesn’t know Is the developmental disability expected to substantially impair ability to live independently? Yes Client refused Documentation of the disability and severity on file No Yes CHRONIC HEALTH CONDITION [All Clients] No Client know Yes Client refused IF TO CHRONIC HEALTH CONDITION SPECIFY “YES” – No Client doesn’t know Currently receiving services/treatment for this condition Yes Client refused No Client doesn’t know Is the condition expected to be of long-continued and indefinite duration and substantially impairs ability to live independently. Yes Client refused Documentation of the disability and severity on file No Yes HIV-AIDS [All Clients] No Client doesn’t know Yes Client refused IF TO HIV-AIDS SPECIFY “YES” – No Client know Currently receiving services/treatment for this condition Yes Client refused No Client doesn’t know Is the condition expected to substantially impair ability to live independently? Yes Client refused Documentation of the disability and severity on file No Yes MENTAL HEALTH PROBLEMS [All Clients]
DISABLING CONDITIONS AND BARRIERS PHYSICAL DISABILITY [All Clients] No Client doesn’t know Yes Client refused IF “YES” TO PHYSICAL DISABILITY – SPECIFY Receiving services for physical disability No Client doesn’t know Yes Client refused Is the physical disability expected to be of long-continued and indefinite duration and substantially impairs ability to live independently. No Client doesn’t know Yes Client refused Documentation of the disability and severity on file No Yes DEVELOPMENTAL DISABILITY [All Clients] No Client doesn’t know Yes Client refused IF “YES” TO DEVELOPMENTAL DISABILITY – SPECIFY Receiving services for developmental disability No Client doesn’t know Yes Client refused Is the developmental disability expected to substantially impair ability to live independently? No Client doesn’t know Yes Client refused Documentation of the disability and severity on file No Yes CHRONIC HEALTH CONDITION [All Clients] No Client know Yes Client refused IF “YES” TO CHRONIC HEALTH CONDITION – SPECIFY Currently receiving services/treatment for this condition No Client doesn’t know Yes Client refused Is the condition expected to be of long-continued and indefinite duration and substantially impairs ability to live independently. No Client doesn’t know Yes Client refused Documentation of the disability and severity on file No Yes HIV-AIDS [All Clients] No Client doesn’t know Yes Client refused IF “YES” TO HIV-AIDS – SPECIFY Currently receiving services/treatment for this condition No Client know Yes Client refused Is the condition expected to substantially impair ability to live independently? No Client doesn’t know Yes Client refused Documentation of the disability and severity on file No Yes MENTAL HEALTH PROBLEMS [All Clients]
Child-Intake-Form-CoC-ESG-Programs.docx