Initial Contact Screening Form

Your First Name: *

Your Last Name: *

Your Phone #: *

Your Email: *

First Name of Individual Interested in Service: *

Last Name of Individual Interested in Service *

Individuals First Initial *

Individuals Last Initial *

Date of Initial Contact (Todays date) *

What services are you interested in? *

Group Day

Community Engagement

Community Coaching

Residential Living

Date of birth *

Age *

Gender *

What is the address of the individual interested in services? *

Timeframe of services needed? * *

Please indicate individuals Level? *

Please indicate individuals Tier? *

Other services utilizing? Referred and/or wait listed *

Does the individual currently participate in any of the following? *

Group Day

Community Engagement

Employment Services

Community Coaching

DISPOSITION of the individual including referral to other services for further assessment, placement on a waiting list for service, or admission to the service *

Reason for service interest or support needed? *

Does this individual display physical aggression towards others? *

Yes

No

How many days a week are you interested in attending? *

Is the individual Wheel Chair Based? *

Yes

No

Authorized Representative First Name *

Authorized Representative Last Name: *

Authorized Representative Phone Number *

Authorized Representative Address *

Additional Information *