BECOME OUR CLIENT

Date Requested

Date Application was Provided to Applicant

Name of Applicant

First

Last

Potential Start Date

Numbers of Days you will be Attending

Do you need transportation service?

Yes
No

Support Coordinator Name

First

Last

Support Coordinator Contact No.

Staff Print Your Name When Delivered

Yes
No

Additional Instruction (IF ANY)

Application Procedure

Step 1
DESTINED FOR CHANGE LLC. Center for Success Program Tour. Both the applicant and his or her parent(s) or guardian(s) should DESTINED FOR CHANGE LLC. Center for Success (ADT) tour before applying to the program. The applicant and parent/guardian must have attended this tour within one year of applying. During this tour, all aspects and goals of the program will be reviewed and discussed during a presentation with an opportunity for questions and answers by the DESTINED FOR CHANGE LLC. staff.
Step 2
Request and Review, DESTINED FOR CHANGE LLC. Center for Success Application Packet: The application packet can be picked up or request to be mailed. All required documents of the Application Packet must be submitted together to complete the process for admission. It is important that the most current information is submitted in order to determine that DESTINED FOR CHANGE LLC. Center is an appropriate placement and that the applicant has the combination of desire, motivation, skill, and experience to be successful in the program. Once DESTINED FOR CHANGE LLC. staff has reviewed the completed application packet, one of the following will take place: - The applicant and parent(s) or guardian(s) will be contacted to set up an interview for admission. - The applicant was not selected and may be encouraged to reapply or be placed on a waiting list.
Step 3
Participate In 30 Days Assessment: Both the applicant and the DESTINED FOR CHANGE LLC. Program Manager will meet with the applicant’s Waiver Support Coordinator to evaluate the program placement and establish program goals to be included in the Individual Program Plan or Implementation Plan.

Admission Agreement For

DESTINED FOR CHANGE LLC. Center for Success is a Day Training Activity Center for adults with developmental disabilities, licensed by the Agency for Persons with Disabilities (APD). This facility is not licensed for, and will not provide nursing care. We are located at 5508 N 50th Street suite 23 Tampa,Fl 33610. Our telephone number is (813) 867-0053 Our business hours are 8:00a.m. to 3:00 p.m. Monday through Friday. Program hours for consumers is base on 6 hour per day. We are closed on holidays mandated by the State of Florida.

We agree to provide the following basic services for the above-named applicant:

- Training in life skills related to the Support Plan goals.
- Training in employment readiness.
- Training in health and wellness.
- Training in the use of technology.
- Plan goals. These goals will be reviewed at least annually and revised as necessary.
- Provide continuous observation, care and supervision as required.

Provisions of our services are subject to the applicant’s continued eligibility as stated in our Entrance and Exit Criteria. Enrollment eligibility may vary in some cases from the basic Entrance and Exit Criteria if extenuating circumstances are present. Enrollment requirements include, but are not restricted to:

- Applicant must be able to follow directions and redirection.
- Applicant will be committed to good attendance, not to exceed 25 program days annually excluding holidays.
- Applicant will not be a danger to self or others.
- Applicant will not be prone to stealing or destroying personal or facility property.
- Applicant will satisfactorily complete a 30-day probationary enrollment period.
- Applicant agrees to abide by DESTINED FOR CHANGE LLC. Center for Success’s Behavior & Attendance Policy contained in this packet.
- Applicant must have acceptable social behavior, verified by previous schools, family, and/or agency personnel as well as the ability to get along with peers, follow rules, and accept supervision.
- Applicant must be able to participate in a personal interview.

Multiple approaches will be used in determining ongoing enrollment in this program. Except in cases where the applicant may be a danger to self or others, a 30-days notice will be given for our intent to dismiss an applicant from this program.

Applicant must agree to comply with the general policies of the facility. They are not to bring medications, special foods or beverages into the facility without the knowledge of the program administrator. DESTINED FOR CHANGE LLC. will not be responsible for any cash, valuables or other personal property brought to the Center unless these items are delivered to administration for safekeeping. A two-week notice of intent to leave this program is requested unless the applicant’s physical or mental condition prevents this.

My signature below as “Applicant” and/or “Applicant’s Authorized Representative” indicates that I have read, or had read and explained to me, the provisions of this agreement and enter this agreement voluntarily.

SIGNATURES OF PARTIES TO THIS AGREEMENT:

Applicant or Authorized Representative:

Date

DESTINED FOR CHANGE LLC Center for Success, Administrator:

Date

*Note: The original agreement shall remain on file with DESTINED FOR CHANGE LLC. Center for Success and a duplicate copy shall be given to the applicant and/or the applicant’s authorized representative

Please check the box below to tell us how you found out about DESTINED FOR CHANGE LLC ?

Applicant Name

First

Last

Date of Birth

Age

Address

Address Line 1

Address Line 2

City

State

Zip Code

Applicant’s Cell Phone:

Applicant’s Home Phone:

Applicant’s Email Address:

Sex

Male
Female
Other

Copy of Applicant’s ID:

Yes
No
Not Sure

Height

Weight

Legal Competency:

Language Spoken in the Home:

Name

First

Last

Relationship

Primary Contact:

Yes
No
Not sure

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone:

Cell Phone:

Work Phone:

Email

Name

First

Last

Relationship:

Primary Contact:

Yes
No
Not sure

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

Email

Primary Care Physician (PCP):

PCP Address:

Address Line 1

Address Line 2

City

State

Zip Code

PCP Phone Number:

In case of emergency what is your hospital preference name and address:

Did you receive the Hepatitis B vaccine?

Yes
No
Not Sure

Results of Hepatitis B test:

Positive
Negative
Not Sure

Are you a known carrier of any disease? (If applicable, please list):

Do you have any special dietary needs? (If yes, please list):

Do you have any food allergies?

Yes
No
Not Sure

If yes, please list all food allergies:

Do you have any medication allergies:

Yes
No
Not Sure

If yes, please list all medication allergies:

LIST OF MEDICATIONS (please include dosage, time and reason):

Requires Other Supports? (If yes, please specify):

If yes to any of the behavioral and/or self-care issues, please explain in detail. Include the most recent date(s) of the occurrences and severity (use another sheet for more writing space):

Applicant Name:

First

Last

Person Rating Applicant:

First

Last

Date

Relationship to Applicant:

Directions

Use the following rubric to provide a score regarding the applicant’s level in Skill Acquisition and a score regarding the applicant’s skill level in Task Completion.
For Skill Acquisition, the scores range from 1-6, with “6” indicating that the applicant does not yet have any experience in learning the skill and “1” indicating that the applicant can consistently demonstrate the skill without any support.
For Task Completion, the scores range from 1-6, with”6” indicating that the applicant does not yet have any experience in completing the task and “1” indicating that the applicant can consistently demonstrate completion of the task without any support.

Skill Acquisition

Score & Description:
(6) No Experience Yet *Applicant does not yet have experience in learning how to do the task.

(5) Non-Compliance *Applicant shows no-compliance in the form of arguing, delaying, ignoring, refusing, or other forms of resistance, in earning how to do the task.

(4) Linguistic Prompting *Applicant requires linguistic prompting in the form of specific verbal instructions and/or spoken cues in learning how to do the task.

(3) Manipulate Prompting *Applicant requires manipulate prompting in the form of modeling, moving materials for the applicant, and/or partial physical cues in learning how to do the task.

(2) Indirect Prompting *Applicant requires indirect prompting in the form of gesturing, visual aids, and/or the close proximity of an observer in learning how to do the task.

(1) Demonstrated Independence *Applicant has demonstrated independence of the skills needed to complete the task in the presence of a non-interfering observer.

Directions

For each of the items below, type in two scores in the form of a number from 1 to 6 for both the Skill Acquisition Score followed by the Task Completion Score in the appropriate box (ex. 6, 5) . This should be to best estimation of the level of the student in each item as related to Skill Acquisition and task Completion.

Cleaning his/her own bedroom

Cleaning his/her own bathroom

Cleaning the kitchen

Cleaning the living room

Keeping clothing clean and organized

Keeping bedding clean and regularly changing bedding

Maintain personal hygiene

Wear proper attire (based on the activity, weather, etc.)

Use morning, evening, and/or other routine

Visit self-care professionals (barbers, salons, etc.)

Using and maintaining a meal plan

Going grocery shopping regularly

Cooking meals regularly

Demonstrating safety awareness in the kitchen (heat safety, cutlery safety)

Use a bank account and its associated debit card

Budgeting regularly and appropriately

Checking the mailbox regularly and sorting incoming mail

Self-advocating in a shared living situation

Reaching mutual agreements in a shared living situation

Self-administering own medication as prescribed or recommended

Obtaining more medication by renewing or refilling

Completing the application process for a job including an interview

Creating a continually updating a resume

Obtaining proper clothing for work experience

Attending and participating at a job for 7 or more hours a week

Monitoring paychecks and depositing them into a bank account

Transporting self back and forth from home and work

Choosing classes to enroll in (college or otherwise)

Requesting accommodations in an academic setting

Using and maintaining or organized binder

Navigating a campus to find classrooms

Attending and participating in class session (college or otherwise)

Planning and completing assignments by their due date

Writing a one-page reflection paper

Planning social activities or get-togethers with others

Attending and participating in social activities

Using public transportation (buses, taxis, Uber/Lyft, etc.)

Attending and participating in volunteer hours

Structuring free time to develop personal interests

Using a fitness routine regularly

I have completed this Applicant Skill Acquisition & Task Completion Inventory truthfully and to the best of my knowledge all information is accurate. I understand that falsifying or omitting information could be grounds for termination from the program.

Person Rating Applicant :

Signature:

Date

Typical Day of Applicant

WHAT DOES YOUR TYPICAL DAY LOOK LIKE? (To be filled out by applicant)
What would a typical day be like for you?
Please include all current pertinent recreational activities as well as areas of interest.
If you need more space, please attach an additional page.

Asian or Pacific Islander: Persons having origins in any of the peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands and Samoa.
African American (not of Hispanic origin): Person having origins in any of the black ethnic groups.
Hispanic: Persons having origins in any of the Mexican, Puerto Rican, Cuban, Central or South American or other Latin Cultures, regardless of ethnicity.
Native American or Alaskan Native: Persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition.
Caucasian (not of Hispanic origin): Persons having origins in any of the original peoples of Europe, North Africa or the Middle East.

RACE AND ETHNICITY TRACKING (Optional)

For purposes of data collection for occasional funding, please mark the box(es) that best describes the applicant’s race/ethnicity category of which she/he identifies with:

I have completed Destined for Change LLC. Center for Success application truthfully to the best of my knowledge, all information is accurate. I understand that falsifying or omitting information could be grounds for termination from the program.

Applicant Name

First

Last

Applicant Signature:

Date

Parent/Guardian Print Name:

First

Last

Parent/Guardian Signature:

First

Last

Date

Welcome To Destined For Change

Application Procedure

Directions

Skill Acquisition

Directions

Typical Day of Applicant

RACE AND ETHNICITY TRACKING (Optional)

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