Person for Whom Services Requested

Name:

Address:

City:

State:

Zip Code:

Contact Person

Name: 

Phone:

Type of Disability

Non-Ambulatory       Fetal Alcohol Syndrome
Blind                            Down's Syndrome
Deaf                             Mental Illness
Assist w/Self-Help         Incontinence
Behavior Issues             Gastric Tube Feeding
Mental Retardation       Mobility Needs
Autism                        24 HR Supervision
Cerebral Palsy               Speech Impairment
Epilepsy                        Non-Verbal
Spina Bifida                   Scoliosis

Other (give details below)