Apd - Application For Services Form Page 2
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6Application for Services
3.
Person Assisting Applicant
Name: _____________________________________________ Relationship to Applicant: ______________________________________
(Last)
(First)
(MI)
Address: ______________________________________________________________________________________________________
Phone #: _______________________________________
Alternate Phone #: ____________________________________________
Email: __________________________________________
Preferred Language of Applicant/Legal Guardian: _____________________
4.
Services Requested
I am requesting services via the Home and Community-Based Services (HCBS) Waiver.
Yes
No
OR
I am requesting services in an Intermediate Care Facility.
Yes
No
I am requesting the following services from the Agency for Persons with Disabilities:
5.
Applicant’s Identity Verification (must check one)
(to be filled out by APD Staff):
FL Driver’s License/ID Card
US Passport
Military/Government Issued Photo ID Card
Certificate of Naturalization/Citizenship
School Photo ID (only accepted for persons under the age of 16)
6.
Applicant’s Legal Status (select all that apply)
:
(to be filled out by APD Staff)
Between the ages of 3 and 18 and under legal custody of his/her parent(s)
Between the ages of 3 and 18 with a court appointed representative
Between the ages of 3 and 18 and the parents have delegated decision making under the Family Care Act using a written power of attorney
or durable power of attorney
18 or older and his/her own representative
18 or older and has delegated in writing decision-making authority related to governmental benefits or medical decisions to someone else by
using a power of attorney or durable power of attorney
18 or older and a court has issued letters of guardianship or guardian advocacy, naming someone other than the applicant as the decision
maker for governmental benefits or medical decisions
Name of legal guardian or guardian advocate, court appointed representative or person delegated decision making authority (if applicable):
______________________________________________
List type of document(s) provided as proof of legal status (if applicable): ____________________________________________________
7.
Community Based Care (CBC) (if No to first question, move to next section)
(to be filled out by APD Staff):
Is this applicant an active Community Based Care (CBC)/Child Welfare services recipient?
YES
NO
If yes, Is he or she receiving out-of- home (foster care) services?
YES
NO
Is he or she receiving in-home (protective supervision) services?
YES
NO
Updated January 21, 2016
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