Family Support Services Application

Family Support Services Application

Thank you for applying for funds through the Georgia State Funded Family Support Program. Please note that State Funded Family Supports are intended to be used as a last resort and you should utilize other programs before applying for this program. Please complete all sections, including your signature at the end of the application. Any application not completed in full will not be considered.
Date of Application: *

MonthDayYear
Date
Individual Name:*

First NameLast Name
Social Security Number: *
Gender:*

MaleFemale
Date of Birth:*

MonthDayYear
Date
Age:*
Race (optional):*

American Indian or Alaskan NativeAfrican AmericanMulti-Racial/Ethnic GroupAsian or Pacific IslanderCaucasian/AngloOther
Ethnicity (optional):*

Not HispanicHispanic or Latino
Insurance Information
Private:
Public (Medicaid) #:
Family Member/Guardian Name:

First NameLast Name
Relationship to Individual:

Legal GuardianParent of Minor ChildGuardian of an Adult IndividualOther
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence*
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Section II: Diagnostic Information
Developmental Disability Diagnosis: Check which of the following disability categories is most relevant to the identified individual:*

Autism Spectrum DisorderIntellectual DisabilityCerebral PalsyMuscular DystrophyNeurological Impairment (Prior to age 22)Developmental Delay (0-8)Traumatic Brain Injury (Prior to age 22)Other
Age at Time of Diagnosis:*
Supporting Documentation:

Documentation of Diagnosis is required. Please attach a copy of the most recent psychological evaluation, Individual Education Plan (IEP), and/or any other evaluations/documentation with diagnostic information. Failure to provide supporting documentation will result in the application not being considered.
Check the supporting documentation attached to this application:*

DBHDD I&E AssessmentSchool IEPPsychological EvaluationSocial Security Disability Determination (SS)Medical VerificationOther
Please attach the above documents here:*

Cancelof
Section III: Current Service Information
Please check ALL current services that the identified individual is receiving:*

New Options Waiver (NOW)Currently on DBHDD Planning ListICWPCCSPDeeming Waiver (Katie Beckett)Vocational RehabilitationFood StampsIndividual Education Plan (IEP)ADRC-Options CounselingCompresensive Waiver (COMP)SOURCEGAPPDBHDD State Funded ServicesChild Care Assistance (CAP)Adoption AssistanceSocial Security Disability (SSDI)Other
Please check all sources of the individuals current natural support network:*

FamilyFriendsChurchSocial GroupsCoworkersSupport GroupOther
Section IV: Service Needs/Requests
From the list below, please check the services/goods your family has identified as needing: After your application has been approved, an assessment will be conducted to determine which services/goods will be awarded based on need and available funding.
Service Needs/Requests:*

Respite CareCommunity Living SupportCommunity AccessSupported EmploymentDental ServicesMedical CareVision CareSpecialized ClothingSpecialized Diagnostic ServicesEnvironmental ModificationsSpecialized Equipment/Assistive TechnologyTherapeutic ServicesCounselingParent/Family TrainingSpecialized NutritionSuppliesIncontinent SuppliesExceptional Disability Related Living CostsTransportation ReimbursementVehicle Adaptation ServicesChild Day Care/After-School ServicesOther Family Support ServicesRecreation/Social Community Integration ActivitiesFinancial and Life Planning AssistanceBehavioral Consultation and Support
Are the services/goods identified above accessible through other sources?*

YesNo
Have the services/goods identified above been denied through other sources?*

YesNo
Services/Goods Requested: Describe the benefit to the family if the services and goods above were funded.*
Section V: Agreement Section

I understand to be eligible for the Family Support Program the individual/applicant must be diagnosed with a developmental disability prior to the age of 22 and live in a family member's home. I hereby confirm that the information given at the time of application is true and accurate to the best of my knowledge.
Individuals Signature (If over 18 years of age)

Clear
Parent/Legal Guardian's Signature*

Clear
Should be Empty:

Family Support Services Application

Insurance Information

Section II: Diagnostic Information

Supporting Documentation:

Section III: Current Service Information

Section IV: Service Needs/Requests

Section V: Agreement Section