Transportation Intake Form Required Preliminary Questions Are you 18 years of age or older? Yes No Are you supported through residential services? Yes No Are you needing transportation to a day program funded through DHSS? Yes No Person's Information Date of Birth MM DD YYYY Name First Name Last Name DMH# Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email Race/Ethnicity American Indian or Alaska Native African American Native Hawaiian or Other Pacific Islander Caucasian (Not Hispanic or Latino) Hispanic or Latino Asian Other Gender Male Female Prefer Not to Answer List all diagnosis Transportation Information Transportation Requested Established Routes Advanced Call Pick-Up Address Destination Required Drop-Off Time Hour Minute Second AM PM Full Address Return Destination Required Pick-Up Time Hour Minute Second AM PM Full Address Estimated Start Date MM DD YYYY Days Riding Per Week Monday Tuesday Wednesday Thursday Friday Riding Times Morning & Afternoon Morning Only Afternoon Only Support Coordination / Referral Source Name First Name Last Name Phone (###) ### #### Email Agency Eitas KCRO CHS Other (Family, Friend, Caregiver, etc.) Funding Source Do you have active Medicaid? Yes No Do you have spend down? Yes No Unknown Amount of Spend Down $ Do you have a Medicaid Waiver? Yes No Unknown Which Medicaid Waiver do you have? Comprehensive Community Support Partnership for Hope Safety Information Guardian or Family Representative Information Name First Name Last Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Information Name First Name Last Name Phone (###) ### #### Name First Name Last Name Phone (###) ### #### Alternative Drop-Off Address Address 1 Address 2 City State/Province Zip/Postal Code Country Adaptive Equipment Used e.g. wheelchair, ramp, hearing aides Form of Communication e.g. verbal, signs, communication device Medical Issues e.g. seizures, allergies, respiratory Preferences that are non-negotiable for this person Thank you!
