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Community Engagement Services Waitlist Form
Support Coordinator/Case Manager Name
*
Support Coordinator/Case Manager Email
*
Support Coordinator/Case Manager Cell Number
*
Individual's Full Name
*
Individual's preferred name
*
Individual's cell phone # (If none, put N/A)
*
Individual's Email (If none, put N/A)
*
Individual's current address
*
Individual's Current Living Situation
*
Legal Guardian(s) Name(s) (If none, put N/A)
*
Legal Guardian Email (If no LG, type N/A. Email required for DocuSign intake forms.)
*
Legal Guardian's Phone Number (If no LG, type N/A)
*
Legal Guardian's Address (must include city and zipcode)
*
Emergency Contact Name
*
Emergency Contact Address (must include city and zipcode)
*
Emergency Contact Phone Number
*
Authorized Representative (if applicable; if not, type N/A)
*
Rep Payee (if applicable; if not, type N/A)
*
Date of Birth (must be 18+)
*
Month
Day
Year
Medicaid ID (If pending, type Pending + last submitted date)
*
Tier
*
Current DD Waiver
*
Individual has to have a waiver for approval?
Submit
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