CE APPLICATION

New adult client request

PLEASE COMPLETE ENTIRE APPLICATION

If you are interested in receiving Conductive Education services for an adult client please complete the application form below. Our conductors will review the information and then followup with you.

After you’ve completed the application, please take some videos that would allow us to see how the prospective client does with the following tasks:

  • Lying on belly and back
  • Rolling over and turning around
  • Sitting up, sitting (both unsupported and supported)
  • Standing up, standing (okay to use whatever equipment they are used to)
  • Communicating (can be verbal communication or use of device)
  • Manipulation (holding things, playing with a puzzle, etc.)
  • Self-care (feeding, buttons, zipper on coat, etc.)

When it’s convenient and a prospective client is local we typically meet with families so we can assess the client and understand their current capabilities and limitations so that we can prepare a program that will meet their specific needs and group them appropriately.  However, when a client lives far away we simply initiate this process via videos. Videos can be emailed to assessments@sarasgarden.org.


Client's Personal Information

Client's Name *

Gender *
FemaleMale

Date of Birth*

Street Address *

City*

State *

Zip Code *

Client Lives With

Next of Kin


Medical and Health Record

Family History
Are there any illnesses / disabilities in the family?

Date of Accident

Any Tremors or Loss of Feeling?
Describe any presence of tremor, stiffness, or loss of feeling in any limbs.

Any Contractures?
Describe the presence of any contractures and their locations.

Any Speech Problems?
Describe any speech/communication problems.

Level of Concentration

Any Memory Problems?
Describe any short or long term memory problems.

Any History of Epilepsy or Seizures?
What kind; how often; how long; main symptoms?

Current Medications
List current medications and possible side effects.

Surgeries
What kind; when?

Allergies
Food, medications etc.

Special Diet
G-tube, etc.

Hearing Tested and Results
When/what results?

Vision Tested and Results
When/what results?

Previous Treatments & Therapies
PT, OT, Speech, other services; how often?

Past Participation in Conductive Education Programs?
When, where?

Other Information / Comments you would like to share


Client Observations

Describe Your Daily Routine
(Weekdays)

Describe Your Daily Routine
(Weekends)

Favorite Leisure Activities in the Home

Favorite Outdoor Leisure Activities

Describe Your Communication Methods

How do You Move Around Indoors?

How do You Move Around Outdoors?

Can You Navigate Stairs?

What are Your Greatest Difficulties at This Time?

Please Share any Other Information you Would Like.


Present Physical Condition

Lying Position - Are you able to:
Lift HeadRoll Over

Sitting Position - Are you able to:
Sit on the FloorSit in a Chair (Supported)Sit in a Chair (Unsupported)

Standing Position - Are you able to:
Stand up From the Floor?Stand (Supported)Stand (Unsupported)

Walking
Are You Able to Take Steps? If So, Please Describe:

Fine Motor Movement
Are you able to grasp and hold different things (blocks, pencil, paper, etc.)?

Self-Reliance
Describe how you eat and drink (is there any problem with chewing or swallowing; special utensils, self-feed).

Bladder Issues
Describe any issues with bladder and bowel continence. Is there a catheter?.

What Special Aides, Furniture do You Use at Home?


General Questions

What Goals do you Have for Yourself?

Do you Expect to Reach Goals with Conductive Education?

How did you Hear About Sara’s Garden?


Confirmation

This Application has been Completed by: *

Relationship *

Date *

Please Check to Confirm Authorization *
I am authorized to provide this detailed medical information on this client to Sara's Garden for consideration in their CE program. Upon review Sara's Garden will contact me regarding an assessment date.

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Contact Us

<p style="text-align: justify;">If you have any questions or would like to receive any additional information on our Sara’s Garden here at Sara's Garden, please feel free to contact us. We would love to address any questions you may have.</p>

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