Priority Waitlist Interest Form OASIS IntroductionHousing | Residential Staffing ServicesVocational Employment Services | Two Year Transition AcademyAutism Works School Program | Positive Behavior SupportFinal Comments0% Complete1 of 5 To ensure we have all the necessary information, please allow a minimum 15 minutes to complete the interest form How did you hear about A New Leaf? * Word of Mouth Search Engine (Google, Bing, etc.) Social Media Community Event Radio Television Newspaper/Online Newspaper Billboard I Don’t Know OtherOther Name of Individual seeking services: * Name of Individual seeking services: First First Last Last Gender: * M F Prefer to self-describe Prefer to self-describe * DOB: * Best Contact Method * PhoneEmailDo not contact directly Phone: * Email Address: Phone: Email Address: * Does the Individual’s Parents/Guardian give consent to collect, use, and disclose the information of the Individual? * Yes No Race: African American American Indian or Alaska Native Asian Caucasian Hispanic Native Hawaiian or Other Pacific Islander Not Specified Are you a member of a federally recognized tribe? Yes No Address: * Address: Address: Address: Address: Address: State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Address: Individual’s Current Physical Housing Type: Please select an optionFamily HomeGroup HomeAlternative Group HomeAgency Companion HomeShared Home (3-4 roommates)IndependentOther Individual's Current Physical Housing Type: Is the Individual seeking service currently employed? Yes No Current employer of Individual seeking service: Primary Diagnosis of the Individual: Does the Individual have a Secondary Diagnosis? Yes No Secondary Diagnosis of the Individual? Does the Individual have a Medical Diagnosis? Yes No Please check all that apply – past & present: Developmental/Intellectual Disability Attention-Deficit/Hyperactivity Disorder (ADHD) Autism Spectrum Disorder Cerebral Palsy Down Syndrome Epilepsy Hearing Impaired Impaired Communication Skills Impaired Sensory Processing Lacking Fine Motor Skills Obsessive-Compulsive Disorder (OCD) Traumatic Brain Injury Vision Impaired/Blindness OtherOther (Options selected do not disqualify the Individual from services) Does the Individual require adaptive equipment? Yes No Where does the Individual require adaptive equipment? In Home In Vehicle In the Workplace Please Describe: Is the Individual currently receiving Developmental Disability Services (DDS) through the state of OK? * Yes No I don’t know Who is the assigned Case Manager? Who is the assigned Case Manager? First Name First Name Last Name Last Name Phone Number: Email Address: What waiver is the Individual on? * Home & Community based waiver In-home support waiver State Funded Services I don’t know What specific type of Community Waiver? * Group Home (GH) Daily Living Support (DLS) I don’t know Are you interested in a Private Pay option? Yes No Does the Individual have an Individual Plan (IP)? Yes No I don’t know Upload the Individual’s Individual Plan (IP): Drop a file here or click to upload Choose File Maximum file size: 10MB (jpg, jpeg, png, pdf) Does the Individual have a Guardian other than self? Yes No Name of Guardian: * Name of Guardian: First First Last Last Relationship to Individual: * Best Contact Method * PhoneEmail Phone of Guardian: * Email of Guardian: Phone of Guardian: Email of Guardian: * Guardian Address: Guardian Address: Guardian Address: Guardian Address: Guardian Address: Guardian Address: State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Guardian Address: Is someone other than the Individual or Guardian (if applicable) filling out this form? * Yes No Name of Form Filler: * Name of Form Filler: First First Last Last What is the Form Filler’s relation to the Individual? Family Case Manager OtherOther Best Contact Method * PhoneEmail Phone of Form Filler: * Email of Form Filler: Phone of Form Filler: Email of Form Filler: * If you are human, leave this field blank. Next
