Apd - Application For Services Form
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6Application for Services
Region/Field Office: _______ Phone #: ____________________________
Name of APD Staff Person:
Date of Application: ___/___/_____
1.
Applicant Information
Name: ____________________________________________________
SS#: * _______________________________________
(Last)
(First)
(MI)
(Suffix)
Address: ___________________________________________________
Medicaid #: ___________________________________
___________________________________________________________
Phone #: ____________________________________
Email: _____________________________________________________
Alternate Phone #: ____________________________
DOB: _______ Sex: ____ Race (for data purposes only):
White;
Black;
Asian;
Native American or Alaskan Native;
Other
Ethnicity (for data purposes only):
USA;
Cambodia;
Cuba;
Ethnic Chinese;
Haiti;
Laos;
Mexico;
Nicaragua;
Poland;
Puerto Rico;
Russia;
Vietnam;
Other Hispanic Country;
Other Asian Country;
Other Foreign Country
Primary DD Diagnosis (must select at least one):
Autism;
Cerebral Palsy;
Intellectual Disability;
Prader-Willi Syndrome;
Spina Bifida;
Down Syndrome; OR,
Between the ages of 3 and 5 and at High Risk of Developing a Developmental Disability (if
selecting this box, please explain):_________________________________________________________________________________
Secondary DD Diagnosis: _______________________________
Mental Health Diagnosis: ____________________________
Do you have a job paying minimum wage or better?
Yes
No If No, are you interested in gainful employment?
Yes
No
1.a. Applicant’s Primary Caregiver Information
Name: _____________________________________________________
DOB: _______________________________________
(Last)
(First)
(MI)
(Suffix)
Phone #: ___________________________________________________
Alternate Phone #: ____________________________
Relationship of Primary Caregiver to Applicant: ____________________________________________________________________
Does the primary caregiver have health issues that prevent them from continuing to provide care?
Yes
No If Yes, please indicate
the medical issues: ___________________________________________________________________________________________
Is the primary caregiver also providing primary care to a minor, elderly person or another person with a disability?
Yes
No If Yes,
please explain: _______________________________________________________________________________________________
Are the current caregiver responsibilities preventing them from being employed?
Yes
No
If the applicant is an adult (over the age of 18) has the applicant been removed from their family home by Adult Protective Services in the last
12 months? (Regardless of the result of the investigation)
Yes
No
2.
Active Duty Military Service Member (if No to the first question, move to the next section)
Is the applicant’s parent or legal guardian an active duty military service member?
Yes
No
If Yes, please identify by name: _____________________________________________________
Was the family transferred to FL as part of military assignment?
Yes
No
If Yes to the above, did the applicant receive home and community-based waiver services in another state?
Yes
No
If Yes to the above, please list services received: ____________________________________________________________________
Did the applicant move to FL to be closer to family while a parent or legal guardian is deployed?
Yes
No
If Yes, please explain: _________________________________________________________________________________________
Attached is a copy of the military service member’s Uniformed Services ID Card
Yes
No
Updated January 21, 2016
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