My Possibilities Program Application

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5-STEP ENROLLMENT PROCESS


Thank you for your interest in applying to My Possibilities.  The application process allows the Admissions Committee, the client and the client’s family to determine whether My Possibilities can best meet the needs of the client applying for admission.


In order to determine eligibility for admission, My Possibilities has established the following requirements that must be met during the admissions process:


Step 1:  Tour our Campus at 3601 Mapleshade Lane; Plano 75075.  Tours are held on the 2nd/4th Tuesday of the month from 9:15 am – 11:00 am. A tour can be scheduled by calling (469) 241-9100.


Step 2:  Complete the on-line Application and submit electronically to My Possibilities - Application can be down-loaded at mypossibilities.org - click on admissions/apply


Step 3:  Submit the non-refundable Application Fee of $200 - Application Fee can be submitted on-line at mypossibilities.org – click on admissions/HIPster application payment or paid by check


Step 4:  Provide requested documents. Once your application has been submitted a member of the admissions team will contact you via email to request documents related to you applicant. 


Step 5:  Intake Interview – Once the Enrollment Packet is complete, a member of the Admission’s Team will contact you to schedule an on-site interview for the applicant and his/her family.  During the Intake Appointment, the applicant and his/her family will have the opportunity to ask questions, clarify information or discuss any concerns they may have.


At the conclusion of the Intake Appointment, a determination will be made as to the next step in the enrollment process. If accepted into the program, you will be eligible to be added to the waiting list for future openings.


If government funds are required for payment, contract and approvals must be in place prior to the commencement of enrollment. 


My Possibilities does not discriminate on the basis of race, color, ethnicity, religion, age, or gender, in its admissions policy or programs.  It is up to the discretion of the Admissions Committee as to who is accepted.







































If YES who do we have permission to talk to/consult






















4. PARENT/CAREGIVER INFORMATION - please fill out completely

























5. EMERGENCY CONTACT   The emergency contact should be a person other than the above stated parent/caregiver/guardian(s). This contact can be that of an additional relative, neighbor or friend who can be contacted in the event that the primary parent/caregiver/guardian(s) are unable to be reached.























How much assistance does client need with the following?























Client’s Primary Care Physician:




Does he/she take any medications?  If so, what kind(s) of medications and what are the administration times?**We prefer you provide a full week’s worth of medication(s) in the original marked prescription bottle(s) with clear instructions. A written waiver signed by the parent/caregiver is required for staff to oversee the self-administration of medication. 




Please Enter a time between 8 AM and 6 PM. you must enter as: 8 AM or 8:00 AM or 1 PM or 2:00 PM, etc.
















































11. CONDITIONS
































Please Enter a time between 8 AM and 6 PM. you must enter as: 8 AM or 8:00 AM or 1 PM or 2:00 PM, etc.




Please Enter a time between 8 AM and 6 PM. you must enter as: 8 AM or 8:00 AM or 1 PM or 2:00 PM, etc.




Please Enter a time between 8 AM and 6 PM. you must enter as: 8 AM or 8:00 AM or 1 PM or 2:00 PM, etc.

OTC MEDICATIONS




FOR ASTHMA MEDICATION OR EPINEPHRINE AUTO-INJECTOR ONLY






13. AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT 




























15. CONSENT TO RECEIVE SERVICES






Therapy





Employment




Respite



Medicaid Provider




Day Habilitation




16. REFERENCES - Please list all that apply:


Personal Reference




School Reference




Job Site














17. HCS/CLASS/TxHML PROVIDER INFORMATION - Current







18. GETTING TO KNOW YOUR HIPSTER - please answer the following questions. 










What personal goals would you like to have him/her work on?



19. PROGRAMS

Morning (8:00 am – 2:00 pm) and Afternoon (12:00 am – 6:00 pm): Our Programs aim to provide the highest quality of continued education for our Hugely Important People. This is accomplished by equipping all of our HIPsters with the knowledge, behavior and skills necessary for leading fulfilling lives by realizing their place in the world, developing aspirations of interdependence, maintaining a sound mind and sound body, developing vocational skills, un-tapping their creative inspirations and discovering their leader within. Through a combination of academic, elective, and vocational classes, our HIPsters move through an individualized schedule made up of classes they choose to advance them towards their personal goals. By participation in a variety of hands-on activities, and community based instruction, HIPsters gain beneficial tools to enhance their lives and the lives of those around them.

 

   Private Pay Cost                                                                      HCS / CLASS / General Revenue

Days per week

Cost

(Per month)

 

Days per week

Cost

(Per month)

3

$550

 

3

To be discussed with Provider

4

$600

 

4

To be discussed with Provider

5

$650

 

5

To be discussed with Provider













































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