Apply for our Independent Living Program

1. Name*

2. Phone Number 1:*

Phone Number 2:

3. Contact Person and Phone number (if other than consumer):

4. Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

5. Date of Birth:*

Email*

Social Security Number

Gender*

Male
Female

7. Do you wish to receive our bi-monthly newsletter?

Yes
No

If yes, how would you like to receive it?

Electronically
Mail

8. Race: (Individuals may select more than one category)*

If Hispanic or Latino, please select:

Mexican
Puerto Rican
Cuban

Other (Please state):

9. Language: (Primarily Spoken)*

English
Spanish

Other:

10. Marital Status:*

11. Living Situation: (Check only one)*

Other:

12. Are you presently employed?*

Yes
No

If yes, show hours worked per week_

Income from work weekly $_

If employed, what is your employment status?

Part Time
Full Time
Supported Employment
Transition Student

If you are presently working, where are you employed?

13. Are you presently retired?*

Yes
No

If so, with what benefits did you retire?

with Company Benefits
with Social Security Benefits

Retirement Social Security Benefits $_

14. Are presently unemployed?*

Yes
No

Of the following which is the one you most identify?*

Seeking Employment
Not Seeking Employment
Never Worked
Receiving Unemployment

Unemployment Benefits $_

15. Have you been in the military?*

Yes
No

16. Are you eligible for veteran’s benefits?*

Yes
No

Veterans #:

17. What is your educational level?*

Have you ever had an IEP?

Yes
No

Are you presently attending school?

Yes
No

If yes, name of school

18. Who referred you to this program?*

19. Disability Type: Primary Disability:*

Sensory/Communicative Impairment
Physical Impairment
Mental Impairment

Secondary Disability (if applicable):

Sensory/Communicative Impairment
Physical Impairment
Mental Impairment

What is your disability?*

20. A. Are you receiving Services or have you received services from: (Check all that apply)

If you checked the Medicare. Medicaid, Food Stamps, TANF, and Workman Compensation please provide the information on the following sections.

Medicare #:

Medicaid #:

Food Stamps $_

TANF $_

Workman Compensation $_

B. If you are receiving SSDI benefits, check all that apply:

Amount received $_

C. If you are receiving SSI benefits, check all that apply:

Amount received $_

21. What is your total monthly income?

22. Have you previously received services through a Center for Independent Living?*

Yes
No

If so, where?

23. Please select the services that will assist you in becoming more independent.

A. Assistive Technology Services

Other:

What is your height?

What is your weight?

B. Independent Living Skills Training and Life Skills Training

C. Other Services

The information contained in this form is true and correct to be the best of my knowledge. Permission is granted to the Independent Living Program to make whatever inquiries might be necessary to verify these statements, so that my IL Coordinator will be able to determine my eligibility for services. In applying for independent living program services, I understand there is a need to collect personal information.

I understand that consumer service record information concerning me will be kept confidential.

I understand that I have the opportunity for a timely review of any dissatisfaction with a determination made by the Ability 1st Utah staff concerning the furnishing or denial of Independent Living Services by contacting Sandra Curcio at 801-373-5044.

I understand that a Client Assistance Program Representative is available to act as my advisor and advocate, and that I may call toll free 1-800-662-9080 or Salt Lake 363-1347 to reach the Disability Law Center / Client Assistance Program (CAP), 205 North 400 West, Salt Lake City, UT 84103.

I understand that services in this program are provided without regard to sex, race, age, religion, color, or national origin according to Title VI of the Civil Rights Act, and Section 504, Rehab Act of 1973, as amended. The Independent Living Program also assures that no group of individuals will be excluded or found ineligible on the basis of type of disability.

Confidentiality Statement

I understand that what is contained in my case file, as well as, what I divulge to Ability 1st Utah staff is held in the strictest confidence except in the cases listed below:

1. I can expect you will divulge information to proper individuals, if I exhibit suicidal behavior or extreme suicidal ideation - i.e., if what I do or say leads you to believe, that I may take my life or otherwise harm myself.
2. I understand you have the obligation to warn the proper individuals if I exhibit tendencies to harm another individual - i.e., you will warn the person who would be harmed, or notify the proper authorities.
3. I also understand that you are mandated by law to report instances of sexual and/or physical abuse and neglect. This includes instances where I may be the victim, as well as, instances where I might be the perpetrator.
4. I also understand that it may be necessary to give information to vendors in order to obtain bids for the purpose of completing my goals.
5. Information may be shared while trying to obtain funding sources - i.e., Utah State Office of Rehabilitation, Utah Assistive Technology Foundation, Medicaid, and Medicare.
6. In case of emergency, Ability 1st Utah staff may contact:

Emergency Contact:*

Phone Number*

Consent*

I certify that I have read the above, and agree to hold Ability 1st Utah, along with its Staff and Board of Directors, harmless in such situations where the above information has been divulged to protect me or other people in my life.

Signature

Signature*

Consumer/Guardian/Representative Signature__________Date

By typing in your full legal name you agree that this is an electronic signature.

Would you like to register to vote? (This information will not affect your eligibility.)

Yes
No

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