828-452-1980

Application for Services

Applicant Info
Guardian Info
Current Address
Address Other (if less than 5 years at current)
Emergency Contact (if guardian cannot be reached)
Financial Info
Please be as specific as possible with the financial information since some services are income/asset based
Social Security
Medicaid
Medicare
Innovation Waver
State Funding
Other Sources (SSI/SSA/etc)
Life Insurance
Savings Account
Trust Fund
401K or 403B account
List all Medical Providers #1
List all Medical Providers #2
List all Medical Providers #3
List all Medications and dosage
List Previous Group Home/AFL Placements
Attachments

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