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)
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First Name
Last Name
What is applicant's gender at birth?
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Male
Female
Email
*
example@example.com
Phone Number
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Please enter a valid phone number.
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
ArcMorris provides a variety of exciting programs- please check ALL programs that you are interested in:
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Residential Program- Group Home
Residential Program- Supervised Apartments
Residential Program- Supported Living* (discontinued by DDD but we can discuss)
Day Habilitation- Traditional
Day Habilitation Without Walls
Prevocational Program- Custodian
Respite- overnight program
Respite- hourly
Respite- day program
Project College
MCARP (Morris County Adaptive Recreational Program including Special Olympics)
Paradise Farm Day Camp
Community Based Supports
Community Inclusion Services
Stand Alone Behavior Support Services
Medical Group Home
Behavioral Group Home
Career Exploration
Other
Who is this application for?
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Please Select
Self
Child- daughter or son (or other)
Sibling
Client (completed by support coordinator or guardian other than parent or sibling)
Other
Please write full name of person completing this form
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First Name
Last Name
Does the applicant receive SSI or SSA or SSDI?
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Yes
Yes all of the above
No
Other
Does the applicant have MEDICAID?
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YES
NO
Other
When would you like to start services?
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-
Month
-
Day
Year
Date
Does the applicant have a legal guardian?
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Yes
No
If yes, please write guardian name
First Name
Last Name
If yes, write guardian email
example@example.com
Have applicant applied for Division of Developmental Disabilities Services and received them?
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Yes, eligible
No, did not apply yet
No, applied but was found not eligible
Do not know anything about the Division services
Does the applicant have a Support Coordinator and ISP?
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Yes
No
If yes, please upload current ISP
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What is applicant's primary disability- mark all that apply as primary based on psychological or neurological evaluations:
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Intellectual Disability
Down Syndrome
Cerebral Palsy
Autism Spectrum Disorder
Fetal Alcohol Syndrome Disorders
Fragile X Syndrome
Williams Syndrome
Prader-Willi Syndrome
Rett Syndrome
Other
Does the applicant have Mental Illness Diagnosis?
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Yes
No
Other
If yes, please mark ALL that apply.
Depression
Anxiety Disorder
Schizophrenia
Post-Traumatic Stress Disorder
ADHD
Borderline Personality Disorder
Eating Disorders
Other
Has the applicant even been hospitalized in Psych ER for any reason?
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Yes
No
If yes, please provide brief explanation
If the applicant has any of the following medical conditions, please indicate below all that apply:
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Epilepsy
Gastrointestinal Issues
Sensory Impairments
Obesity that requires special diet
Musculoskeletal Problems
Respiratory Conditions
Dental Issues
Cardiovascular Conditions
Endocrine Conditions including diabetes
Feeding Tube
None
Allergies
Other
Is applicant verbal?
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Yes
No
Uses communication device
How does applicant ambulate?
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Ambulatory
Walker
Cane
Wheelchair
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
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How did you hear about ArcMorris
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Please Select
Website
Social Media
From current client
From ArcMorris Employee
At an event/fair
Other
Thank You- Click Here to Submit Your Application
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