Intake Form

Want to be a part of something great, feel connected and get involved in a joy- inspired community?

Thank you for your interest in blue dot social and community wellness. We are located in Asbury Park, NJ and we are an approved DDD provider, servicing adults with neuro and developmental differences. Please fill out this form and we will get back to you!
What is blue dot?

blue dot is dedicated to meaningful social engagement and community-based volunteering for adults with neuro and developmental differences. By facilitating community connections, partnering with nonprofits and personalizing services for each client, blue dot is committed to enhancing and advocating for the physical, cognitive and social health for our community. blue dot aims to promote community inclusion, spread joy and give back to the local community and environment.
Tell us about you!*

First NameLast NameNickname
Birth Date

MonthDayYear
What town are you from? *
E-mail*
Phone #*
Format: (000) 000-0000.
Tell us what you like to do and what inspires joy for you!
interests/hobbies/passions
Tells us some things you do NOT like:
the things that might bother you
Services I am interested in (hold command to select multiple options):
What high school do/did you attend?
Do you have reliable transportation?
Do you work or volunteer, if so, tell us about it!
What other programs or activities are you involved in?
I communicate my needs by:
Are you comfortable walking long distances and being physically active with a group?
I can use the bathroom and perform self care:
I have a history of elopement:
Do you take medication? If so, can you self-administer?
If applicable, please tell us about any behavioral supports needed:
If applicable, please list any medical or physical indications:
seizures, allergies, etc
Please include 2 references so we can get to know you better !
people that know you well, but not family members!
Tell us more about yourself. Why would you like to be a part of the blue dot community? Do you have any special skills or talents? What are you future goals?
Thank you so you much! We look forward to meeting you!
How did you hear about us?
Should be Empty:

Want to be a part of something great, feel connected and get involved in a joy- inspired community?

What is blue dot?