Treatment & Home Connections Grant Applications
Applicant Information
Full Name:
*
First Name
Last Name
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
Please enter a valid phone number.
Email:
*
example@example.com
Applicant DOB
*
-
Month
-
Day
Year
Date
Relationship to Applicant
*
Desired Grant Value
*
Purpose of Treatment Grant:
*
Is the applicant a citizen of the United States?
*
Yes
No
Does applicant have an Autism Spectrum Disorder (ASD) Diagnosis?
*
Yes
No
Is applicant related to a CCI board member?
*
Yes
No
Date of Diagnosis:
*
-
Month
-
Day
Year
Date
Diagnostic Physician
*
Current Forms of ASD Treatment
Does applicant have a current treatment plan?
*
Yes
No
Form of Treatment
Company
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Treatment Supervisor
Supervisor Email
Form of Treatment
Company
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Treatment Supervisor
Supervisor Email
Form of Treatment
Company
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Treatment Supervisor
Supervisor Email
Priority Treatment Goals
Area of Development
*
Current Rate of Behavior
*
Goal Rate of Behavior
*
Support Members
*
Primary Treatment Location
*
(Treatment Towards Goal)
From
*
-
Month
-
Day
Year
Date
To
*
-
Month
-
Day
Year
Date
Is this goal currently in-progress?
*
Yes
No
Area of Development
Current Rate of Behavior
Goal Rate of Behavior
Support Members
Primary Treatment Location
(Treatment Towards Goal)
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Is this goal currently in-progress?
Yes
No
Area of Development
Current Rate of Behavior
Goal Rate of Behavior
Support Members
Primary Treatment Location
(Treatment Towards Goal)
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Is this goal currently in-progress?
Yes
No
Guardian Contact
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Relationship to Applicant
*
PLEASE ATTACH a copy of the following: State Issued ID, Treatment Bill, Treatment Plan
*
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Proof of ASD Diagnosis
*
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PLEASE ATTACH a medical document that reflects an ASD diagnosis
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Treatment Summary
*
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PLEASE ATTACH a treatment document that reflects the needed support in which the grant will be uses. Examples: current treatment plan, assessment, session note, treatment supervisor summary
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Treatment Invoice / Receipt
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PLEASE ATTACH a copy of a current invoice or past receipt in accordance with the requested grant amount. Invoice must include company letter head in which the grant will be issued to OR past receipt must include the legal name of the applying guardian in which the grant will be issued to.
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of
Home Equipment/ Repair Cost
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PLEAST ATTACH a proof of cost document (example: repair estimate, item cost from website/ store) OR past receipt in accordance with the past repair / needed equipment.
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Legal ID & Signature
*
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PLEASE ATTACH a legal ID & signature.
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Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge.If this application leads to Connections Center, Inc. issuing the applicant a Treatment Connection Grant, Iunderstand that false or misleading information in my application or interview may result in the termination offunds.
Signature
*
Date
*
-
Month
-
Day
Year
Date
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