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Adult Day Program
Residential Support Services
Individualized Home Supports
Crisis Residential
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Housing Openings
Elton Hills Home
Overland Home
Ridgeview Home
Sierra Home
Timberwood Home
Villa Haven
Villa Home
About
What We Do
Our Story
Our Staff
Employee Benefits
Contact
FAQ
Careers
Youth ILS Application
Please provide the most information that you accurately can. This information will benefit you and your progress throughout your time with this program. Please inform the Program Director of any mistakes or changes that need to be made.
Date
*
MM
DD
YYYY
Referred by
Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
May we communicate with you via text messages?
*
Yes
No
Email Address
*
Age
*
Gender
*
Male
Female
Living Situation
*
With Family/Guardian
Group/Foster Care
Social Security Number
*
MA Number
Guardian Information
Guardian Name
Guardian Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Guardian Phone
Alternate Phone
Emergency Contact Information
Emergency Contact Name
*
Relationship to Applicant
*
Emergency Contact Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact Phone
*
Emergency Contact Alternate Phone
*
Emergency Contact 2 Information
Emergency Contact 2 Name
Relationship to Applicant
Emergency Contact 2 Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact 2 Phone
Emergency Contact 2 Alternate Phone
Social Worker Information
Social Worker Name
*
County
*
Social Worker Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Social Worker Phone
*
Social Worker Email
*
Funding
*
CADI (Consumer Support Grant)
DD Waiver
Private Pay
Doctor Information
Physician Name
*
Clinic
*
Clinic Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Physician Phone
*
Clinic Phone
(if different from Physician phone)
Health Information
Diagnosis
*
Date of last clinic visit
*
MM
DD
YYYY
Reason
*
Allergies
*
Hearing
*
Good
Impaired
Hearing Aids
Deaf
Vision
*
Good
Impaired
Glasses
Blind
Ambulation
*
Self
Cane/walker
Wheelchair
Other
Toileting
*
Self
Needs Assistance
Wears Protective Garment
Personal Hygiene
*
Self
Needs Assistance
Other
Medical Conditions
*
Medications
*
Diet Restrictions
*
Diabetic
*
Yes
No
Insulin Dependent
*
Yes
No
Current Transportation
*
Would you be interested in using our transportation services?
*
About Your Child
What are your favorite qualities about your child?
*
What goals and/or skills are you hoping your child will gain through our program?
*
Please describe any behaviors your child has, if any. (Note: Children are not "disqualified" from our program based on behaviors.)
*
What school does your child attend?
*
What days/hours during the school year do you desire for your child to attend? We currently offer hours M-F.
*
What days/hours during the summer do you desire for your child to attend? (Please note: During the summer we offer a choice between a morning (8-11am) and afternoon (1-4pm) time slot M-F. We do not currently offer hours on the weekend.)
*
Additional Notes
Is there anything else you'd like to tell us about your child?
How did you hear about SMB Disability Solutions?
*
Indeed
Facebook
Website
Advertisement
SMB Employee
Other
Other
Section 8
Signature (Parent or Guardian if child is under 18)
*
By entering my name below, I verify that all of the information provided is correct to the best of my knowledge.
First Name
Last Name
Thank you!
