FINAL - Client Waitlist

1
I have permission to complete this form for a specific human.This ensures our efforts to get in contact are met with positive and engaging conversation.
YESNO
2
Approximate Start Date of Services:This will be discussed with more depth. It helps to gauge how to manage other work obligations.
Date
Year
Month
Day
3
Best method to communicate with or about our services.Preference for text, calls, email or in person matter for planning purposes.
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Ok
Ok
4
Human's Name:* This field is required.This helps to ensure I know who I am speaking to and about.
First Name
Last Name
5
Human or Representative Phone Number* This field is required.This ensures having easy reference to most current information.
Please enter a valid phone number.
6
Home AddressThis ensures we know the services area of the human and can mail things quickly.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Human or Representative Email* This field is required.This ensures having easy reference to most current information.
example@example.com
8
Case Manager Name* This field is required.This ensures having easy reference to most current information.
First Name
Last Name
9
Case Manager Email* This field is required.This ensures having easy reference to most current information.
example@example.com
10
Case Manager Phone Number* This field is required.This ensures having easy reference to most current information.
Please enter a valid phone number.
11
Talk about anything relevant and updates not in documentation?
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Ok
Ok
12
Please share the following information. * This field is required.HIPAA compliant way to upload any documentation which supports our work. Required due to scope of services: Full ISP, Safety Plans and Protocols. May be required if relevant to services: BSP, Nursing Care Plan, Other supplemental supports that are relevant to care. Helpful for extra context: Relevant paperwork or photographs showing any current situational details or information the ISP doesn't capture well like non billable needs which need a specific plan, service or community resource.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Cancelof
13
Support Days and Times:The more availability the faster and easier a good fit can be found.
14
How many miles "per the ISP" do you want to have for services?
10 miles or less
25 miles or less
50 miles or less
100 miles or less
150 miles or less
200 miles or less
250 miles or less
201+ miles
15
What training and experiences are important for your staff to have?
Someone familiar with specific I/DD conditions.
Someone familiar with another language and/or experience with communication devices.
Someone familiar with adaptive equipment, mobility issues, physical limitations and transfers.
Someone familiar with trauma informed care and mental support tools.
Someone familiar with gaining and keeping resources.
Someone familiar with advocacy.
Other
16
Are there any boundaries or traumas you want to share? We cannot discriminate and will attempt to find good fit regarding your preferences to the extent possible.
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Ok
Ok
17
If a staff cancels, what do you need?
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Ok
Ok
18
What language(s) or communication is needed to support you?
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Ok
Ok
19
Approval Status
Approved
Not Approved
20
Approval Limitations
21
Entered into Jotform/eXPRS?
Yes
No
Should be Empty: