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  • The Arc.
    Davidson County
    & Greater Nashville

  • For people with intellectual and developmental disabilities
    Achieve With Us.
  • Dear Prospective Family Support participant,

  • We need information regarding your disability to determine eligibility for Family Support Services. If you already have medical documentation that describes your disability and that it is permanent/lifelong, please send copies for eligibility review. You may also choose to obtain the appropriate medical documentation from your physician or specialist without our assistance or need for the enclosed Release of Information. If you do not have this information, you may choose to complete and sign the enclosed Release of Information form and we will request documentation from your designated physician/specialist.

  • THIS RELEASE IS NOT REQUIRED AND YOU DO HAVE THE RIGHT TO DECLINE
  • Family Support Office
    The Arc Davidson County & Greater Nashville
  • 545 Mainstream Drive • Suite 110 • Nashville, TN 37228
    Phone: 615-321-5699 / Fax: 615-322-9184
    www.arcdc.org/familysupport

  • The Arc.

  • Davidson County
    & Greater Nashville
  • For people with intellectual and developmental disabilities
    Achieve With Us.

  • Dear Prospective Family Support Participant,

  • As part of our ongoing efforts to ensure compliance with State Guidelines for Family Support, we need to determine if you are eligible for the Family Support program. Once this form is thoroughly completed and returned to the Family Support office, a questionnaire will be sent to the listed physician for completion.
  • This statement is to serve as both notification and Release of Information (ROI) to send to your physician along with a questionnaire regarding your disability/disabilities. The questions will be based on the seven criteria that were used to determine initial eligibility.
  • DOB:
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • ******YOU MUST INCLUDE YOUR PHYSICIAN'S FAX NUMBER OR EMAIL.
    ROI SHEETS WITHOUT THE FAX NUMBER OR EMAIL WILL NOT BE ACCEPTED*****
  • Date:
     - -
  • 545 Mainstream Drive, Suite 110, Nashville, TN 37228
    Phone: 615-321-5699 / Fax: 615-322-9184
    www.arcdc.org/familysupport
  • Image field 29

  • Family Support Intake Form

  • Date of Birth
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Potential Support Services Needed/Requested (Check services needed):
  • Do you (the person applying for Family Support) receive any of the following? (Check all that apply)
  • What type of insurance do you (the person applying for Family Support) have?
  • Have you (the person applying for the Family Support) applied for or do you receive any of the following? (Check all that apply)
  • To comply with Title VI, the following information is requested:

  • 1. RACE (Check all that apply) (federal standards consider "Hispanic/Latino to be an Ethnicity, to be answered below, separate from "Race")

  • RACE

  • 2. ETHNICITY (if self-identified as "Hispanic/Latino, "please answer the Race question separately above and then "Hispanic/Latino" here

  • ETHNICITY
  • Primary Disability – Check which of the following "major disability categories" is most relevant to person services are being requested for (as a primary diagnosis):
  • Primary Disability
  • Did the person's primary disability occur:
  • Did the person's primary disability occur:
  • NOTES: Please explain in detail how the Family Support funds would assist your family. Based on the diagnosis of the applicant, what needs is he dash she unable to obtain without these supports? How would the applicant's daily life be improved with this assistance? Use additional paper if necessary.
  • By signing and dating this intake form, I, the person applying or the legal representative, indicate that all the information above is true and accurate. Furthermore, I understand that providing invalid, inaccurate or incomplete information could be considered as fraud and may result in criminal investigation and disqualification from the program which would prevent reapplication in subsequent years.
  • Date
     - -
  • If someone other than the family/applicant dual is making a referral:
  • Format: (000) 000-0000.

  • Functional Limitations Assessment

  • If you are unable to complete this form, please ask your caregiver and /or family member
    Must check all applicable boxes

  • 1. Self-Care: Refers to the daily personal skills required to maintain a healthy existence.

  • Do you need assistance with the following (check all that apply)

  • 2. Self-direction: Refers to an individual's ability to make safe, wise decisions independently.

  • Do you need assistance with the following (check all that apply)

  • 3. Receptive and Expressive Language: Refers to individual's ability to understand what others are saying and to communicate his or her own thoughts

  • 4. Learning: Refers to individual's ability to learn without additional supports and services

  • TURN OVER
  • 5. Mobility: Refers to the ability to move around and use his or her physical abilities in the environment
  • 6. Capacity for Independent Living: Refers to an ability to engage in the activities needed to live and work
  • 7. Economic Self-Sufficiency: Refers to the ability to obtain and retain a job in a competitive work environment
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