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Day Support Pre-Screening Questionnaire

Applicant Information

Gender
Home Address

Emergency Contact

Guardian/Representative (if applicable)

Medical Information

Seizure History
Mobility Needs

Support Needs

Communication Method
Behavior Support Needs

Program Goals

Check all that apply

Transportation

Will the applicant use Paratransit transportation services?

Funding Source

Private Pay
Medicaid Waiver

Authorizations & Signature

By signing below, I certify that the above information is accurate and complete. I give permission for this individual to participate in U & I’s Day Support Program.