ArcMorris Application for Services Part One

ArcMorris Application for Services Part One

Please complete the form and our Intake Coordinator will be in touch to schedule the initial meeting and review information about our programs
Applicant Name (person who wants to receive services from ArcMorris)

First NameLast Name
What is applicant's gender at birth?
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ArcMorris provides a variety of exciting programs- please check ALL programs that you are interested in:

Other
Who is this application for?
Please write full name of person completing this form

First NameLast Name
Does the applicant receive SSI or SSA or SSDI?

Other
Does the applicant have MEDICAID?

Other
When would you like to start services?

MonthDayYear
Date
Does the applicant have a legal guardian?
If yes, please write guardian name

First NameLast Name
If yes, write guardian email
example@example.com
Have applicant applied for Division of Developmental Disabilities Services and received them?
Does the applicant have a Support Coordinator and ISP?
If yes, please upload current ISP

Cancelof
What is applicant's primary disability- mark all that apply as primary based on psychological or neurological evaluations:

Other
Does the applicant have Mental Illness Diagnosis?

Other
If yes, please mark ALL that apply.

Other
Has the applicant even been hospitalized in Psych ER for any reason?
If yes, please provide brief explanation
If the applicant has any of the following medical conditions, please indicate below all that apply:

Other
Is applicant verbal?
How does applicant ambulate?

Other
Does the applicant has any fears: heights, elevators, dark, spiders, etc.
What is important when you chose a provider? You can bring an example of quality services as per your expectation
How did you hear about ArcMorris
Should be Empty: