Intake Form
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
Court Ordered Legal Guardian
Yes
No (If yes, documentation must be provided)
Upload State ID
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Parent/Legal Guardian: Name
First Name
Last Name
Parent/Legal Guardian: Phone Number
Please enter a valid phone number.
Parent/Legal Guardian: Email
example@example.com
DVR Counselor:
DDDS TCM
Columbus TCM
Transportation Type
*
Public Transportation
Paratransit
Own Vehicle
None
LifeSpan Waiver
Yes
No (If yes, documentation must be provided)
Do you have the following Support Documents? (If yes, documents must be provided)
ICAP Behavioral Support Plan
Individual Support Plan
Personal Focus Worksheet
Support Needs
ELP Nursing Assessment
Do you have any known allergies?
Yes
No (If yes, describe below)
Know Allergies
If Yes, the agency requires a copy of your emergency plan.
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AFPS Employee making contact:
Emergency Contact Form
Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Medical Information
Allergies
Chronic Medical Conditions
Medications/Doses/Frequency
Diagnoses
Submit
Should be Empty: