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Contact Us
Join Us
Who We Are
About Arc
Board Members
Leadership
Publications
Quality & Compliance
News & Press
Join Our Team
What We Do
Day Services
Residential Services
Horizons Clinic
Respite and Recreation
Employment Supports
Community Habilitation
Contract Services
Get Involved
Family Advocacy
Become a Member
Annual Appeal
Sensory Garden
Planned Giving
Legacy of Love
Volunteer
Butterfly Gallery
Resources
For Parents and Guardians
For Care Managers
For More Information
Events
Sponsorship
Arc Race
Dinner
Bowling For All
Contact Us
OPWDD Supported Employment Services Application
Applicant Information
Applicant Name
Date
Phone
Date Of Birth
Address
City
State
Select Option
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP
Medicaid #
Waiver Enrolled
Select Option
Yes
No
Self-Directed
If yes, provide copy of self-directed budget.
Select Option
Yes
No
Applying For
SEMP Intensive
SEMP Extended
Current Services
Day Hab
Res Hab
Comm Hab
Vocational
Other
Self-Employed
Yes
No
Referral from ACCES-VR
Yes
No
Date of ACCES-VR Closure
Family Contact
Name
Phone
Address
City
State
Select Option
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP
Residential Provider Contact
Name
Phone
Address
City
State
Select Option
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP
Care Manager Contact
Care Manager Name
Care Manager Phone
Care Manager Email
Work Information
Please list your volunteer and/or work history (if currently employed, include present job details)
What type of work are you interested in?
Food Service
Janitorial
Customer Service
Clerical
Other
Mobility
Independent
Physical Assistance
Walker
Wheelchair
Dining
Independent
Choking Risk
Food needs to be prepared (cut up/ground)
Food allergies
Other Dining needs (If Applicable)
Work Accommodations
Independent
Assistance needed with writing
Assistance needed with reading
Cannot lift more than 25lbs
Cannot stand for more than 15 minutes
Adaptive equipment needed
Other
Supervision in the Community
Independent
General Monitoring
Hours of alone time
Visual checks
Transportation
Drives independently
Uses public transport (i.e. Centro Bus, taxi service, etc.)
Relies on support
Other
Interested in travel training?
Yes
No
Behavioral Concerns
Socially Inappropriate
Select Option
Not Applicable
Not This Year
Occasionally Less Than Once A Month
Monthly About Once A Month
Weekly About Once A Week
Frequently Several Times A Week
Daily Once A Day Or More
Emotional Outbursts
Select Option
Not Applicable
Not This Year
Occasionally Less Than Once A Month
Monthly About Once A Month
Weekly About Once A Week
Frequently Several Times A Week
Daily Once A Day Or More
Verbally Abusive
Select Option
Not Applicable
Not This Year
Occasionally Less Than Once A Month
Monthly About Once A Month
Weekly About Once A Week
Frequently Several Times A Week
Daily Once A Day Or More
Harasses Others
Select Option
Not Applicable
Not This Year
Occasionally Less Than Once A Month
Monthly About Once A Month
Weekly About Once A Week
Frequently Several Times A Week
Daily Once A Day Or More
Elopement
Select Option
Not Applicable
Not This Year
Occasionally Less Than Once A Month
Monthly About Once A Month
Weekly About Once A Week
Frequently Several Times A Week
Daily Once A Day Or More
Steals
Select Option
Not Applicable
Not This Year
Occasionally Less Than Once A Month
Monthly About Once A Month
Weekly About Once A Week
Frequently Several Times A Week
Daily Once A Day Or More
Additional Information
Additional information regarding the above or any other medical or physical restrictions, barriers to employment, needs, or concerns
Please Attach Documents
Applicant’s Most Current Life Plan
Waiver Notice of Decision (NOD, all pages)
Current LCED
Initial LCED (with Physician Signature)
Psychological Evaluation
Letter of Eligibility
OPWDD Approval Letter to receive SEMP services (RSA/SARF)
Medicaid Card
Any vocational assessments previously administered
Self-Direct Budget (If Applicable)
Identification documents (for I-9 Employer identification verification)
Copy of Social Security Card, Birth Certificate, Permit/License/Non-Drivers ID as applicable
Copy of recent Pay Stub (If currently employed)
For verification of minimum wage requirement
Resume (If Applicable)
Completed By
Date
Submit