Application for Services
Grey areas are for completion by APD office staff only.
Area Office: _____
Phone #: ____________________________
Name of APD Staff Person:
Date of Application:
1.
Services Requested
I am requesting participation in either the Family and Supported
I am requesting the following services from the Agency for Persons
Living or the Developmental Disabilities Home and Community-
with Disabilities:
Based Services Waivers. Yes
No
OR
II am requesting to be served in an intermediate care facility.
Yes
No
2.
Person for Whom Support and Services Are Requested
3.
Person Assisting Applicant
Name:________________________________________________
Name:__________________________________________
(Last)
(first)
(MI)
(Suffix)
(Last)
(first)
(MI)
SS#: *________________________________________________
Relationship to Applicant: __________________________
Medicaid #: ___________________________________________
Address: _______________________________________
Address:______________________________________________
_______________________________________________
_____________________________________________________
Phone #: _______________________________________
Phone #:______________________________________________
Alternate Phone #: _______________________________
Alternate Phone #: _____________________________________
Email: _________________________________________
Email: _______________________________________________
Is this person an active Community Based Care (CBC)/Child Welfare
services recipient?
YES
NO
DOB: ________________________________ Sex: _______
If Yes:
Is he or she receiving out-of- home (foster care) services?
Legal Status:___________________________________________
YES
NO
(see instructions)
Is he or she receiving in-home (protective supervision) services?
Preferred Language of Applicant/Guardian: __________________
YES
NO
4.
Residency: Please check all that apply:
5.
Eligibility Assessments:
Florida Resident
US Citizen
Resident Alien
I agree to participate in assessment(s) that may be needed to find out
if I am eligible for services provided by APD.
Place of Birth: ________________________________________
Yes No
(state)
country)
Assessments Needed: ____________________________
To receive services from APD, the applicant must be domiciled in
Florida, and be a U.S. citizen or resident alien.
_______________________________________________
_______________________________________________
Type of documentation provided to show residency and ID (birth
certificate, Green Card, driver’s license, school photo ID, etc.):
_______________________________________________
_____________________________________________________
__________________________________
Page 1
FORM TITLE: APPLICATION FOR SERVICES, RULE 65G-4.016
FORM NUMBER: 10-007
YEAR: 2007