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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
Respite/Programs 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, please provide a copy of Self-Directed Contact.
Select Option
Yes
No
Current Services
Day Hab
Res Hab
Comm Hab
Vocational
Other
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
Care Manager Contact
Care Manager
Care Manager Phone
Care Manager Email
Care Manager CCO
Special Needs
Mobility
Independent
Physical Assistance
Walker
Wheelchair
Clinic Needs
Physical Therapy
Occupational Therapy
Social Work
Guardianship
Do you have transportation to and from the program?
Yes
No
Medical Needs
Seizure Disorder
Insulin Monitoring
Insulin administration
Tube feeding
Hoyer lift
Medication administration
Lifesaving devise (epi pen, VNS)
Other
Behavioral Concerns
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
Property Destruction
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
Physically Assaults 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
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
Self-Injurious
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
PICA
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
Smears Feces
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
Inappropriate Sexual Behavior
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
Please specify any additional information regarding the above or any other medical or physical restrictions, needs or concerns
Please Attach
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
Proof of PPD (2-step needed)
Approved SARF (if applicable)
Dining Guidelines (if available)
Self-Directed Budget (If Applicable)
Submit