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2019-05-17T13:48:41+00:00
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Relationship to Individual (Required)
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Family Member
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Best time to be reached
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Choose a location
Alabama- PHP Alabama Region V Office
Alabama- PHP Alabama Region IV Office
Florida- PHP Fern Park
Florida- PHP Fern Park WINGS Habilitation Center
Illinois- HELP Adloff Place
Illinois- HELP Piasa Manor
Illinois- HELP Lebanon Terrace
Lousiana- DDMS Louisiana Baton Rouge Region
Lousiana- DDMS Louisiana New Orleans Region
Texas- DDMS Beaumont
Texas- DDMS Houston
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Utah-DDMS Utah Provo Care Center
Utah-DDMS Utah Bungalow Care Center
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Utah-DDMS Utah, inc. Eastside Care Center
Utah-DDMS Utah Lindon Care and Training Center
Utah-DDMS Utah Hidden Hollow Care Center
Utah-DDMS Utah North Side Center
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Name (Required)
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Birth Date
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Is this Individual eligible receiving services:
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Individual's current living arrangement:
Home with family
ICF/IDD Facility
Group Home
Check all that apply:
Attention-Deficit/Hyperactivity Disorder
Autism Spectrum Disorder
Cerebral Palsy
Fetal Alcohol Spectrum Disorders
Language and Speech Disorders
Epilepsy
Fragile X Syndrome
Down Syndrome
Hearing Loss
Intellectual Disability
Kernicterus
Spina bifida
Learning Disorders
Muscular Dystrophy
Tourette Syndrome
Traumatic Brain Injury
Additional information about the individual (Medical or behavioral needs)
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