intake Interest Application
Applicant Information
Name: Testing Date:
Date of birth:	SSN:	Phone:
Current address:
City:	State:	ZIP Code:
Is the applicant conserved? If yes, by whom:
care giver/parental Contact
Parent or Legal Guardian:
Relationship to applicant:	Phone:
Email address:
NATURE of inquiry
To be considered eligible, a disability must have originated before the age of eighteen, be likely to continue indefinitely, and constitute a substantial disability. The eligible conditions are the following (Please mark the applicable condition under which you are applying): __Intellectual Disability: A disorder characterized by significant deficits in both cognitive abilities and adaptive functioning. __Cerebral Palsy: A neurological condition occurring from birth or early infancy resulting in an inability to voluntarily control muscular activity, and resulting in significant deficits in motor adaptive functioning and/or cognitive abilities. __Epilepsy: A disorder of the central nervous system in which the major symptoms are seizures. Eligibility is based on a seizure disorder that is uncontrolled or poorly controlled, despite medical compliance and medical intervention. __Autism Spectrum Disorder: A syndrome characterized by impairments in social interaction (withdrawal, failure to engage in interaction with peers or adults), nonverbal communication skills, and ability to develop and maintain relationships. Individuals may engage in repetitive activities or a limited repertoire of activities. __Fifth Condition: This category includes disabling conditions found to be closely related to intellectual disability or requiring treatment similar to that required for individuals with intellectual disability. Please note that conditions such as Attention Deficit Disorder, Learning Disability, & Language Disorders alone are not eligible conditions. ******Once submitted, an intake service coordinator will contact you within 72 hours******