Client Services App for Solin Sanctuary LLC

Client Services Application

Introduce Your Child!
We're thrilled that you've come into our sphere, and look forward to getting to connect with you, and see how we can serve our I/DD friends/family!

Solin Sanctuary is currently a small agency, prioritizing great service for our clients & employees.

We've kept this form reasonably short, to get things going. We'll plan to talk once we receive your application, and see what we can do. Cheers!
Client's Name

First NameLast Name
Client's Age
Client's Birthday

MonthDayYear
Date
Your Name (Parent or Guardian)

First NameLast Name
Your Relationship to Client?
i.e. Mom, Dad, Guardian, Aunt, etc.
Your Phone Number
Format: (000) 000-0000.
Your Email
example@example.com
Residence Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you applying to be the paid support person for the Client?
Does Client currently have a DSP or PSW?
Client's Case Manager Name

First NameLast Name
Case Manager's Phone Number
Format: (000) 000-0000.
Which County do you live in?
i.e. Multnomah, Marion, Lane, Washington, etc.
Is Client currently in school?
Name of the school they currently attend?
Education: Do you have a high school diploma or better, and/or equivalent experience?
How did you hear about us; did someone refer you?
i.e. website, a friend, ODDS, etc.
Do we have your permission to include images &/or videos of your child in social media posts, slideshows, newsletters, etc.?
Have you lived outside of Oregon for 60 days or more within the last 5 years?
Addresses outside of Oregon - Please list addresses/year outside of Oregon
i.e. in another state or country
Names/aliases - Do you have other names or aliases you use?
Names/aliases: Please list
i.e. maiden name, surname, etc.
Thank you for your interest and taking the time to fill this out. We look forward to connecting, and making the world a better place together!
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Client Services Application