The Homestead

Placement Application Form


If you need any help completing this application, please call (515) 967-4369.

You may either submit this application one of two ways;
Online Submission -OR- Print and Mail the Application

Click Here to Print the form.


This application is for an initial screening.  Once accepted to the waiting list, the following information will be required before consideration for placement.

  • A brief social history.

  • A brief medical history including a recent physical, primary physician's name and number, and a consent for release of medical information.

  • For persons currently receiving services from another agency, a copy of their latest Individualized Program Plan

  • For persons who have been through a vocational rehabilitation evaluation, a copy of the evaluation report

  • Recent photograph of the applicant
Application Referred From:
  Physician ICF/MR
  Court Family
  DHS Co. S.W.

  Other Referral

             


You may also mail the completed application
and supporting documents to:

Attention: Admissions
The Homestead     
8272 NE University
Runnells Iowa 50237

Individual completing application (full name)
Email Address
Phone Number
Relationship to applicant


Services provided by The Homestead
Check the services in which you are applying
Youth ICF/MR services in one of two 4 bedroom duplexes in Altoona Iowa.
Adult ICF/MR services in one of six, 4 bedroom homes, at the rural Runnells location 20 minutes from downtown Des Moines
Supported Community Living for adults:  Support while living in an apartment or home with a city of town. (May be alone or with 2-3 roommates also requiring supported community living.) May be for a few hours a week or when ever the individual is in the home.
Supported Community Living for children:  Support while living in the home of parent/guardian.
Note: If a copy of a psychological report is not easily available, an IEP (from school) or an ICP (from a county case manager or social worker stating a diagnosis) is acceptable
Vocational Day Program for individuals over the age of 16.
Supported Employments services for individuals over the age of 16.
Academic Achievement Program


Applicant Information
Application Date
First Name
Last Name
Middle Initial
Date Admission Desired
Present Street Address
City
State
Zip Code
Present Phone Number
Birth Date
Sex Male        Female
Medicaid Number
Medicare Number
Other Insurance (please specify)
Has the applicant ever received a Formal Diagnosis of Autism, Aspergers, Other? No Diagnosis Performed

Autism       Aspergers     
Other  

Date Diagnosis Performed
Diagnosis/Degree of Mental Retardation
None      Mild      Moderate      Severe

List I.Q.   Unknown

Other Information
Does the applicant have seizures?
Yes    No
Description of the frequency and severity
Does the applicant have any physical limitations, use any adaptive devices (wheelchair, shoe inserts, braces, walker, etc. ?)
Yes    No
Description

Prior Living Arrangements (Most Recent first)
Place (Address) From Date Through Date
Other Agency Involvement (vocational, private social service agencies, other providers, etc.


Family Information
Parent/Guardian 1. 2.
First Name
Last Name
Middle Initial
Relationship to Applicant
Present Street Address
City
State
Zip Code
Present Phone Number
Place of Employment
Position
Natural Parent's Marital Status
If remarried, list step-parent


Financial Information
County of Financial Responsibility
Case Worker
Street Address
City
State
Zip Code
Phone Number


Medical Information
List Current Medications
Name Dosage Frequency Prescribed for
Additional Medications
Does applicant require supervision taking medications? Yes    No
Does applicant have any allergies? (check all that apply) Medication       Food       Other  
Description
 
The Homestead's vocational program involves working with all aspects of gardening from early spring to late fall.  Residents work outside the majority of the time, handling plants, weeds, grasses, flowers, fruits and vegetables.
Are there any medical conditions, allergies or medications that would interfere with the applicant's participation in these activities? Yes    No                     
Description


Educational / Vocational
What type of educational experiences has the applicant received?
Has the applicant ever been employed? Yes    No
if yes, has the applicant received special assistance from school, Vocational Rehabilitation or an employment service provider agency? Yes    No                     
Description
If, employed - Employer Name or vocational agency
Address
City
State
Zip Code
If employed, Job Responsibilities


General Comments
Comment on what the application can do well  (Strengths)
Comment on what areas the application needs improvement or training
(dressing self, staying on task, cooking, self-injurious behavior, etc..)