Concept for Community Support Intake for Services

Concept for Community Support Intake for Services
Please complete the following information indicating the services requesting for; Concept’s Core Services are not limited to: Community Living Services; Supported Living Services; Personal Support Services; Community Development Services; Employment Services; Nursing Services; Transportation Services; Respite Services.

We are always here to support you every step of the way!!!

If you are applying to work at Concept for Community Support please click here
Person Support Personal Information

The person support is the individual interested in receiving services
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
Concept only serves individuals who are 21 years of age or older
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which of these describe you? Select all that apply: *

1. White2. Black or African American3. Hispanic or Latino4. Asian5. American Indian or Alaskan Native6. Native Hawaiian or another Pacific Islander7. Middle Eastern or North African8. I prefer not to answer.9. Other
Gender*
Preferred Pronouns*
Primary Language Spoken*
Ethnicity*
Legal Status*
Are you diagnosed with intellectual or developmental disabilities?*

YesNo
If you answered YES to the above question, please explain when
Check the funding that best describes your services*

Community Pathways WaiverCommunity Supports WaiverState Funded Services (Supports only)My waiver is still pending/about to get assistance with my waiverApproved WaiverI do not receive funding from DDA.
Are you in an emergency situation? (Examples: At risk of homelessness or institutionalization)*

YesNo
Please describe your emergency (if applicable)
If you are a Transitioning Youth, what is your date of discharge/graduation?

MonthDayYear
Date
Which of our services are you interested in? (Select as many as necessary)*

Community Living services (Ratio)Supported Living ServicesCommunity Development Services (Ratio)Personal Support ServicesNursing Support ServicesTransportation ServicesRespite Services
Which REGION are you requesting services from?*

CMROEMROSMROWMRO
Do you want to receive Concept's services in the home or apartment where you currently live?*

YesNo
Do you already have your own apartment or house (separate from your family's house)?*

YesNo
Primary Emergency Contact Information & Relationship
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Emergency Contact Information & Relationship
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Diagnosis & History
Please list your diagnosis below*
Medical History*
Social History*
Person Completing this form

If the applicant is not the one completing this intake form, please enter the information of the individual completing the form below.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Relationship to applicant
Service Coordinator (CCS) Information
Name*

First NameLast Name
Agency*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
If you have questions about the services or programs of Concept for Community Support, please contact us at any time. Our staff are ready to assist you.
Should be Empty:

Concept for Community Support Intake for Services

Person Support Personal Information

Primary Emergency Contact Information & Relationship

Secondary Emergency Contact Information & Relationship

Diagnosis & History

Person Completing this form

Service Coordinator (CCS) Information