Intake Form – Aspire Center for Adolescents & Adults

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Home
Events
Intake Form
Get Involved
What We Do
Who We Are

Aspire Center Intake Form

Please fill out the form below in order to access services provided by the Aspire Center, either for yourself, or a loved one. If you prefer to download, print and deliver a paper form, download the Aspire Center Intake Form in PDF Format.

Name of Person Applying for Support Services

Date of Birth

Phone

Name of Parent/Spouse/Legal Representative if different from above:

Family Address

Phone

Potential Support Services Needed/Requested-Please check all that apply

Life Skills Services Day Care Respite Group Social Activities Individual Counseling Vocational Training Employment Services Program Assistance with Legal Paperwork (Guardianship, etc…) Other-Put details in next field

Other Support Services Requests

What type of insurance does the person applying for support have?

Primary Disability-Check which of the following disability categories is most relevant to the person with a developmental disability as a primary diagnosis

Autism Celebral Palsy Deaf and/or Blind Orthopedic Impairment/Physical Disability Health Impairment Traumatic Brain Injury Emotional Disturbance Intellectual Disability Spinal Cord Injury Neurological Impairment Other Specific Learning Disabilities-Details in next section

Please note any specifics or other diagnoses here

Did this person’s primary disability occur:

NOTES: Please explain how the Aspire Center can assist your family. How would the applicant’s daily life be improved with this assistance? Use additional sheets if necessary.

By Signing this Intake Form, I, the person applying or their legal representative, indicate that all of the information is true and accurate. Furthermore, I understand that providing invalid, inaccurate, incomplete information could be considered as fraud and may result in criminal investigation and disqualification from the program which would prevent re-application in subsequent years.

Email: admin@acaamv.org

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