NEXT Intake Form

If yes, please fill out the contact information below.
Our NEXT program is designed to support individuals with a 5:1 staff ratio. This means each participant must be able to transition efficiently, work well with the group, and be successfully engaged in programming with this ratio. A Sidekick will always be present but their time is divided among all 5 participants. The Sidekick's goal is to help with the quality of programming and to provide assistance when needed to support individual growth. If you have specific questions about what this may look like for yourself or your loved one, please feel free to email next@benjaminshope.net.
I have read through the FAQ section of the website.*

YesNo
NEXT is designed to provide a 5:1 participant to staff ratio. Is this ratio adequate to support the needs of the individual?*

YesNo
Participant Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender*
Title/Relation
Diagnosis*
Name of person filling out this form*

First NameLast Name
Relationship to Participant*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Title/Relation
What aspirational goals does your participant have? (Check all that apply)*

Future EmploymentGrowth in Daily Living SkillsGrowth in Leisure SkillsFriendship
If the participant has a goal of future employment, what type of job?

Level of ADL Abilities*

Rows	Independent	Verbal or Visual Prompts	Physical Assistance
Toileting
Dressing
Eating
Mobility
Self-Administration of Medication

Does the participant have any of the following?*

Behavior Status*

Rows	Frequently	Occasionally	Rarely	Not at All
Aggression to Self
Aggression to Others
Property Destruction
Verbal Aggression
Inappropriate Sexual Behaviors
Non-Compliance
Suicidal Ideation
Elopement
Compulsive Behaviors
PICA
Other

If you'd wish to further explain any of the above behaviors or list any behaviors not listed above please do so here:
What level of dialogue represents the participant? (Check all that apply)*

I am not traditionally verbalI verbally communicate my basic needsI communicate utilizing a deviceI am traditionally conversantI have a reliable yes and noI have echolaliaI communicate with sign languageI communicate via RPM
Past Schooling, Extracurricular Activities/Interests, Programs, and Volunteering:*
What are the key things the enable the participant to be successful in programming/job/school setting?*
Please share any challenges the participant has experienced in prior programming/job/school setting*
What staff was provided in prior setting in which the participant was successful?*
Can we contact former teachers/job contacts/employers to learn more about the participant?*

NoYes
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What would be your preferred amount of days of programming?*

5 Days a week (Monday-Friday)3 Days a week (Mon/Wed/Fri)2 Days a week (Tue/Thur)Unsure
Should be Empty: