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