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Get family intake form 2022-2024

Signature of Person Supported or Legal Representative Date Return to The Arc Williamson County 129 West Fowlkes Street Suite 151 Franklin TN 37064 615-790-5815 ext. Family Support Intake Form Date 2017-2018 Name of Family Member with a Severe or Developmental Disability Social Security Date of Birth Name of Primary Family Member s if different than above Family s Address Phone County Email Address Reason for Referral to Family Support include information on the impact of disability on family Primary Disability Check which of the following major disability categories is most relevant to the family member with a severe disability as a primary diagnosis Autism Cerebral Palsy Deaf and/or Blind Health Impairment Traumatic Brain Injury Other Intellectual Disability Neurological Impairment Orthopedic Impairment/ Physical Disability Spinal Cord Injury To comply with Title VI the following information is requested Caucasian African-American Hispanic Female Asian Male When did the person s primary disability occur Prior to age 22 At age 22 or after Potential Support Services Needed/Requested Check services needed Before/After Care Home Modifications Behavior Services Home Maker Services Day Care Nursing/Nurses Aide Specialized Equip. Repair/Maintenance Nutrition/Cloth/Supplies Training Recreation/Summer Camp Vehicle Modifications 1 Page Emergency Living Expenses Counseling Personal Assistance Respite Transportation Health Related What other service s does the applicant or family members receive Check all that apply Adoption Assistance CHOICES Waiver Medicaid Medicare DIDD Waivers Nursing Services Food Stamps OPTIONS Program Foster Care Private Insurance Residential Services Income Supported Living Tenn. Early Intervention System TennCare Vocational Rehabilitation PACE ECF Choices Waiver Is there any other information you would like for us to know at this time Name of Person Completing Form Would you also like to sign up for a complimentary ARC membership for 2017-18 Yes No By signing and dating this Intake Form I the person supported or legal representative indicate that all of the information above is correct.

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