Clear The Form
DDD-1332AFORPF (9-07) – PAGE 2
INDIVIDUAL’S NAME (Last, First, M.I.)
DATE
PROVIDER EXPERTISE:
SERVICE
SERVICE
SERVICE
SERVICE
SERVICE
*Positive Behavior Support
*Client Intervention Techniques (CIT) Level 1
*Client Intervention Techniques (CIT) Level 2
Spanish speaking
Sign language
Other language (Specify)
Gender preference requested by individual
Male
Male
Male
Male
Male
(Specify one)
Female
Female
Female
Female
Female
No preference
No preference
No preference
No preference
No preference
*Medication monitoring/administration
Implementing/following therapy
home programs
*Lift up to/transfer 30 lbs.
*Lift up to/transfer 40 lbs.
*Lift up to/transfer 50 lbs.
*Lift up to/transfer 50+ lbs.
THERAPY PROVIDER EXPERTISE:
Mobility and gait training
Oral motor/feeding/swallowing
Neuro-developmental therapy
Auditory integration
Sensory integration
Cranial sacral
Home modification
Tscharnuler Akademie for
Movement Organization (TAMO)
SUPPORT COORDINATOR’S NAME (Please Print)
SUPPORT COORDINATOR’S SIGNATURE
DATE
COMMENTS
Equal Opportunity Employer/Program ♦ Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans
with Disability Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975, the
Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex,
national origin, age, and disability. The Department must make a reasonable accommodation to allow a person with a disability to take
part in a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters
for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any
other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes to
an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability,
please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for further
information about this policy, contact the Division of Developmental Disabilities ADA Coordinator at (602) 542-0419; TTY/TDD
Services: 7-1-1.
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