Adaptive Care Solutions Inquiry Form
Please fill out this form to tell us about your needs and how we can assist.
Your Information
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
I am a...
*
Please Select
Medicaid NOW/COMP Waiver Recipient
Family Member / Guardian of Waiver Recipient
Occupational Therapist
Case Manager
Support Coordinator
Other
Participant Details
Medicaid NOW/COMP Waiver Participant Full Name
*
Georgia County
*
Participant Age
*
NOW/COMP Medicaid Waiver Status
*
Please Select
Self-Directed
Not Self-Directed
No Waiver
Unsure / Need Guidance
Adaptation Needs
Services of Interest (Select all that apply — optional)
Soft Wall Paneling
Interlock Flooring
Sensory-Aware Lighting
Safe Room Conversions
Door & Hardware Adaptations
Window Safety
Visual Calming & Color
Acoustic Dampening
Other
Timeline / Urgency
*
Please Select
As soon as possible
Within 1 month
Within 3 months
Flexible / Not urgent
Message *
*
Consent to Contact
Submit Inquiry
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