Maryland Interest Form
Please provide your contact information and let us know your role. Whether you are a client, family member, case manager, support coordinator, or other. This helps us understand how we can best assist you.
Your Name
*
First Name
Last Name
Your Email
*
example@example.com
How did you hear about us?
*
Please Select
Facebook Group
A Support Broker
A CCS
From a friend
Other
Your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you already working with a participant (or are a participant?)
*
Yes
No
Who are you?
*
Participant
Parent/Legally Responsible Person (LRP)
Staff member for someone on a DDA wavier (Not LRP)
CCS
Support Broker
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What county are you in?
*
Please Select
Allegany
Anne Arundel
Baltimore
Baltimore City
Calvert
Caroline
Carroll
Cecil
Charles
Dorchester
Frederick
Garrett
Harford
Howard
Kent
Montgomery
Prince George's
Queen Anne's
St. Mary's
Somerset
Talbot
Washington
Wicomico
Worcester
How far are you willing to commute?
*
Please Select
<= 15 mins
<= 30 mins
<= 45 mins
<= 1 hour
Upload your resume
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Full Name of Participant
*
First Name
Last Name
Participants Date of Birth
*
-
Month
-
Day
Year
Date
Does the participant have an intellectual and/or developmental disability? (Autism, Down Syndrome, Cerebral Palsy, etc.)
Yes
No
Is the participant on the MD Community Pathways Waiver? (or formerly community pathways/Family Supports)
*
Please Select
Yes
No
Is the participant under 18?
*
Please Select
Yes
No
Does the participant have a Behavior Support Plan?
*
Please Select
Yes
No
Unsure
Needs Mandt Training
Does the participant receive nursing supports?
*
Please Select
Yes
No
Unsure
Identify Delegating Nurse
Does the participant require medication administration on the clock by CMT licensed staff?
Please Select
Yes
No
Unsure
CMT required
How many hours of Personal Supports does the particpant have? (Or you would like to have Clairo Care manage)
*
How many hours of Community Development does the participant have? (Or you would like to have Clairo Care manage)
*
How many hours of Respite does the participant have? (Or you would like to have Clairo Care manage)
*
Does the participant qualify for Personal Supports enhanced?
*
Please Select
Yes
No
Unsure
Does the participant qualify for CDS 1:1?
*
Please Select
Yes
No
Unsure
County where participant lives
Please Select
Allegany
Anne Arundel
Baltimore
Baltimore City
Calvert
Caroline
Carroll
Cecil
Charles
Dorchester
Frederick
Garrett
Harford
Howard
Kent
Montgomery
Prince George's
Queen Anne's
St. Mary's
Somerset
Talbot
Washington
Wicomico
Worcester
Coordinator of Community Services (CCS) Email
*
example@example.com
I have a caregiver in mind
*
Yes
No
Please describe services needed
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I agree to receive communications by text message or email about I/DD services from Clairo Care. You may opt out later.
Thank you for reaching out!
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