Member Intake Form
Parent / Guardian Name:
*
First Name
Last Name
Parent / Guardian Address
*
Street Address
Street Address Line 2
City
Zip Code
Cross Streets
What Are Your Cross Streets ???
*
Parent / Guardian Phone Number:
*
What's A Good Phone Number ???
Format: (000) 000-0000.
Parent / Guardian Email Address:
*
What's Your Email Address ???
What's The Best Way To Reach You ???
*
Text / SMS
Phone Calls
Email
Child / Member Information
Child / Member Name:
*
First Name
Last Name
Child / Member Birth Date:
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Child's Birth Date
Child / Member Gender:
*
Please Select
Girl
Boy
Do You Have A Current Provider ?
*
Please Select
Yes
No
If Yes, Will the Provider be transferring to Acadia Care Group ?
*
Please Select
Yes
No
N/A
Approximately How Many Hours Is The Member Approved For ?
*
Rows
Hours Per Week
Hours Per Week
Hours Per Week
Respite
Attendant Care
Habilitation Care
Where Are The Hours Currently Assigned ?
Who Is The DDD Support Coordinator ?
*
What Is The Support Coordinator's Contact Information ?
*
Is the Child/Member Approved For DDD Services ?
*
Yes
No
Not Sure
Is the Child/Member Approved For ALTCS Services ?
*
Yes
No
Not Sure
Submit
Should be Empty: