Caring Hands Inc. Application – English DDA

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info@caringhandsinc.org
410-461-2814

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Home
About
Caring Hand Referral
Services
Resources
Location
Staff Portal

Home
About
Caring Hand Referral
Services
Resources
Location
Staff Portal

Home
About
Caring Hand Referral
Services
Resources
Location
Staff Portal

Home
About
Caring Hand Referral
Services
Resources
Location
Staff Portal

Home
About
Caring Hand Referral
Services
Resources
Location
Staff Portal

Caring Hands Refferal

Apply Now

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Name *

First

Middle

Last

Email *

County of Residence

Are you a resident of Maryland? *

Yes
No

Have you ever applied for Medical Assistance in Maryland?

Yes
No

If yes, when?

Medical Assistance Number

Managed Care Organization (MCO)

Primary Care Physician

Regional Office

Supportive documentation attached to this application as available:

Yes
No

Documents Attached

Medicaid Card
Social Security Card

Please check all disabilities that you have been diagnosed with:

Autism
Deafness/Severe hearing impairment
Speech/Language impairment
Behavioral problems
Epilepsy/Seizure disorder
Spina bifida
Blindness/Severe visual impairment
Head injury
Spinal cord injury
Cerebral palsy
Intellectual Disability
other neurological impairment
Chemical dependency (Includes alcoholism)
Multiple sclerosis
Mental illness
Cystic fibrosis
Orthopedic impairment
Other

Please attach copies of the following reports if appropriate, to support your disability, and note their attachment by checking them off below:

Medical Records
Neuropsychological Evaluations
Psychological Evaluations
Special Education Records
Vocational Evaluations
Other professional assessments

Please Identify:

HOW DO YOU GET AROUND?

I walk independently.
I can walk unaided, but with difficulty
I require supportive devices when I walk.
I use a power wheelchair.
I use a manual wheelchair.
I use a scooter.
I am unable to move independently
Other.

DO YOU REQUIRE ASSISTANCE?

I do not need assistance
I need occasional assistance. Several hours per day up to 3 days per week.
I need minimal daily assistance. 1-2 hours per day
I need substantial daily assistance. 8 hours or more per day
I need continuous assistance when I am awake.
I need continuous 24 hours per day assistance.
Other.

HOW DO YOU COMMUNICATE?

I speak clearly and can be understood.
My speech is difficult to understand.
I use gestures to communicate.
I use sign language to communicate
I require a communication device to communicate
I need help from others to communicate.
Other.

DO YOU USE ANY OF THESE SERVICES?

Speech Therapy
Occupational Therapy
Physical Therapy
Specialized Medical Care
Behavioral Support Service
Counseling
Psychiatric Treatment
Other.

PERSONAL SKILLS

EATING
DRESSING
BATHING
TOILETING
GROOMING
TRANSFERS IN/OUT OF BED
PREPARES SIMPLE FOOD
COMPLETES HOUSEHOLD TASKS
USES PUBLIC TRANSPORTATION
USES THE TELEPHONE
KNOWS WHAT TO DO IN AN EMERGENCY

COMPLETELY INDEPENDENT

EATING
DRESSING
BATHING
TOILETING
GROOMING
TRANSFERS IN/OUT OF BED
PREPARES SIMPLE FOOD
COMPLETES HOUSEHOLD TASKS
USES PUBLIC TRANSPORTATION
USES THE TELEPHONE
KNOWS WHAT TO DO IN AN EMERGENCY

NEEDS ASSISTANCE

EATING
DRESSING
BATHING
TOILETING
GROOMING
TRANSFERS IN/OUT OF BED
PREPARES SIMPLE FOOD
COMPLETES HOUSEHOLD TASKS
USES PUBLIC TRANSPORTATION
USES THE TELEPHONE
KNOWS WHAT TO DO IN AN EMERGENCY

COMPLETELY DEPENDENT

EATING
DRESSING
BATHING
TOILETING
GROOMING
TRANSFERS IN/OUT OF BED
PREPARES SIMPLE FOOD
COMPLETES HOUSEHOLD TASKS
USES PUBLIC TRANSPORTATION
USES THE TELEPHONE
KNOWS WHAT TO DO IN AN EMERGENCY

Other (Please List):

AGENCY

Dept. of Social Services (DSS)
Board of Education (Local School System)
Local Health Dept
Area Office on Aging (AAA)
Div. of Rehabilitation Services (DORS
Mental Health Services
Nursing Home Services
Assisted Living Services

Are there any other agencies or programs not listed above that are helping you now, or that have you on a waiting list?

Yes
No

If yes, please list the agencies/programs. *

PROGRAM

Autism Waiver
Personal Care (Medicaid Service)
Living at Home Waiver
Medical Day Care Waiver
Waiver for Older Adults
Model Waiver for Medically Fragile Children
REM (Rare and Expensive Case Management Program)
Traumatic Brain Injury Waiver

APPLIED

Autism Waiver
Personal Care (Medicaid Service)
Living at Home Waiver
Medical Day Care Waiver
Waiver for Older Adults
Model Waiver for Medically Fragile Children
REM (Rare and Expensive Case Management Program)
Traumatic Brain Injury Waiver

CURRENTLY SERVED

Autism Waiver
Personal Care (Medicaid Service)
Living at Home Waiver
Medical Day Care Waiver
Waiver for Older Adults
Model Waiver for Medically Fragile Children
REM (Rare and Expensive Case Management Program)
Traumatic Brain Injury Waiver

PREVIOUSLY SERVED

Autism Waiver
Personal Care (Medicaid Service)
Living at Home Waiver
Medical Day Care Waiver
Waiver for Older Adults
Model Waiver for Medically Fragile Children
REM (Rare and Expensive Case Management Program)
Traumatic Brain Injury Waiver

APPLIED

Dept. of Social Services (DSS)
Board of Education (Local School System)
Local Health Dept
Area Office on Aging (AAA)
Div. of Rehabilitation Services (DORS
Mental Health Services
Assisted Living Services

CURRENTLY SERVED

Dept. of Social Services (DSS)
Board of Education (Local School System)
Local Health Dept
Area Office on Aging (AAA)
Div. of Rehabilitation Services (DORS
Mental Health Services
Assisted Living Services

SERVED IN THE PAST

Dept. of Social Services (DSS)
Board of Education (Local School System)
Local Health Dept
Area Office on Aging (AAA)
Div. of Rehabilitation Services (DORS
Mental Health Services
Assisted Living Services

HAVE NOT APPLIED

Dept. of Social Services (DSS)
Board of Education (Local School System)
Local Health Dept
Area Office on Aging (AAA)
Div. of Rehabilitation Services (DORS
Mental Health Services
Assisted Living Services

*

First

Middle

Last

Social Security Number

Professional/Agency Name: *

Regional Office Contact

need: to: this

Printed Name *

Relationship to Applicant *

Witness *

Please check any title that best describes the role of the person whose name and information is provided on this page:

Primary Caregiver
Legal Guardian
Contact Person

*

First

Middle

Last

County of Residence

Email *

Name of agency, if applicable, acting as the primary caregiver, legal guardian, or contact person:

Does the applicant reside with the primary caregiver?

Yes
No

Relationship to the Applicant:

Self
Family Member
Not Related
Public/Private Agency

If Family Member, please specify relationship:

Briefly describe any circumstances that may be causing difficulty for the primary caregiver.

Contact 1 — Name *

Contact 1 — Relationship to Applicant *

Contact 1 — Email *

Applicant’s Sex:

Female
Male

Is the Applicant of:

Hispanic Origin
Latino Origin

Applicant’s Race (more than one selection can be made):

American Indian / Alaskan Native
Asian
Black / African American
Native Hawaiian / Other Pacific Islander
White

Applicant’s Marital Status:

Single
Married
Divorced
Widowed

Applicant’s Country of Origin:

Primary Spoken Language:

Additional Comments:

Caring Hands, Inc. is dedicated to delivering compassionate, inclusive, and holistic care that empowers individuals to live with dignity, independence, and purpose.

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About
Caring Hand Referral
Services
Resources
Location
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CONTACT INFO

info@caringhandsinc.org
410-461-2814
2027 Suffolk Road Suite 1
Finksburg,MD 21048