APSI Request for Service Application


All Fields are REQUIRED. Please enter "N/A" if not applicable.

1. Demographics


2. Referring Party Information

Please check best description of your role to the applicant:

Please identify the professional primary contact.

Please identify the personal primary contact. Check if same as referring party information

Does this person have a Do Not Resuscitate Order? If yes, must attach order with this application.

Does this person have a Living Will? If yes, must attach with this application.

Does this person have a Power of Attorney? If yes, must attach with this application.

Does this person have a burial account? If yes, must attach with this application.


3. Eligibility Requirements

Is the person 18 years old or older? (Must include a copy of birth certificate)

Yes: yes, more than 18. No: <= 18

Is the person a resident of the State of Ohio?

County Board of Developmental Disabilities Eligible?

Evidence of county board eligibility required. Provide a copy of either the Ohio Eligibility
Determination Instrument (OEDI) or Level of Care (LOC). APSI provides service as the entity of last resort. Referral source is required to identify less restrictive options that were considered.

Other guardianship options:

Name / Agency:

Telephone number

Address:

Email Address:

Reason unable to provide guardianship:

Healthcare power of attorney

Name / Agency:

Telephone Number

Address:

Reason unable to provide guardianship:

APSI provides service as the entity of last resort. Referral source is required to identify next of kin contacted for consideration for guardianship and reason they cannot be
guardian.

Full Name

Telephone number

Address:

Email Address:

Reason unable to provide guardianship:

Date Contacted


4. Service Need

Has the person recently lost a primary caregiver?

If yes, was the person a:

If yes, when did this loss occur?

Why is this caregiver not availiable?

Can this person communicate their wishes & needs?

Person’s residential address:

Provider name and contact information:

Type of setting:

Person’s day service address:

Type of day services

Does the person need assistance in making decisions and explaining their reasoning?

If yes, who currently assists the person with decision making?

Does the person need assistance in acquiring needed supports?

Why is the person being referred for guardianship services?

As the referral source, what do you want APSI to do?

Has the person received an expert evaluation identifying a need for protective services?

If yes must attach a completed Expert Evaluation completed less than 60 days prior to this application. Expert Evaluation must be signed by physician or licensed psychologist.


All information on this form must be completed and requested supplemental documentation must be provided in order for this request to be considered.


Check the following attachments required to be included in this application:

Check if the additional information is included in this application:


5. File Attachments

Attach file:

Hint: zip your files if you want to attach more than one file.



Signatures