Name
*
Email
*
example@example.com
Phone
*
Format: (000) 000-0000.
Relation
*
Resident
*
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Diagnoses
*
Any Behavioral Diagnosis?
*
Yes
No
If yes, please list
Current City & State
*
Current Living Arrangement
*
Timeframe
*
Tell Us
*
Are they 18+ years old, and a high school graduate at the time of inquiry and intake?
*
Yes
No
Has a diagnosed intellectual or developmental disability?
*
Yes
No
Is able to complete his/her daily needs (bathing, dressing, feeding), access his/her physical environment, and live independently with minimal assistance?
*
Yes
No
Communicates their needs effectively?
*
Yes
No
Works, volunteers, or is enrolled in a community college, trade school, or attends a day-training program?
*
Yes
No
Is accustomed to contributing to “family-style” chores and activities, such as cooking and cleaning?
*
Yes
No
Enjoys interacting, socially, and respects social boundaries of others?
*
Yes
No
Is comfortable with a dynamic schedule, including attending center/community-based events?
*
Yes
No
Is free from patterns of aggression or abuse toward self and others?
*
Yes
No
Is able to show proof of income?
*
Yes
No
How did you hear about Coral Reef?
*
Please agree to the following:
*
I have read and understood the admissions criteria for Coral Reef.
I have read and understood the monthly cost for room and board for Coral Reef and am able to meet those requirements.
Ready to Submit Inquiry
Should be Empty: