Intake Form - ADULT

Thank you for your interest in THE PALMETTO PARTNERSHIP.

Your input helps us locate services and support in our area that you are seeking.

Please provide as much information and detail as possible, so that we will have the background we need to find appropriate resources. The more information we have, the more help we can provide.

Contact Information:

First Name *

Last Name *

Age *

Gender *

Email Address *

Daytime Phone *

Address 1 *

City *

State *

Zip Code *

Would you like to receive emails about resources, news and events in our area? *

Background/Medical Information:

Are you verbal? *

Do you have a formal diagnosis of a disability? *

If yes, please answer the following: 1. Where were you evaluated? 2. Who performed the evaluation? 3. What was the date of the evaluation? 4. What was the diagnosis? (Please be specific.)

Do you live independently? *

What is the name and location of your primary healthcare provider? Do you see any specialists? *

Do you have any siblings? Do any of the siblings have disabilities? *

Do you receive Medicaid/TEFRA, SSI, or any other type of financial assistance? *

Do you have a case worker? If yes, what agency provided the case worker? *

Please list any support services you receive for ASD, or other disabilities:

Please list any agencies where you receive services or participate in programs, such as Vocational Rehab, or DDSN:

What are your favorite activities? *

What frightens or upsets you? Any phobias or obsessive behavior?

Do you have a history of verbal/physical aggression or self-injurious behavior? If so, please describe the circumstances, frequency and how long since this has occured. *

Do you have a driver's license or permit? *

Did you complete high school? *

Did you attend college? If so, did you graduate? Please share any degrees you hold, or other academic acheivements: *

Are you currently employed? Please share your work history: *

Do you have family or support, locally? Do you have the opportunity to socialize or network with others? *

What services or resources would most benefit you, or your family? Are there specific needs that you have that we can help address? *

How did you hear about our organization? *

Please share any additional information you would like for us to know:

Would you like to schedule an appointment with a Family Support Consultant? (This consultation will be held over the phone, or at our Resource Center. We will contact you to arrange a date and time.) Our services are free and open to the public.
**OUR OFFICE WILL BE CLOSED FOR REMODELING THROUGH MAY 1, 2024. WE WILL RESUME WEEKLY SERVICES AT THAT TIME.**

Thank you for taking the time to complete the intake form. We are so glad you reached out to us, and hope to provide you with the support and resources that you need.

For information on various agencies and organizations that provide disability services and resources, please go to the RESOURCE LINKS TAB on our website: www.palmettopartnership.org

REMEMBER... YOU ARE NOT ALONE!

The mission of THE PALMETTO PARTNERSHIP of All 4 Autism is to increase the quality of life of those with disabilities, and their families, by providing free resources, support and advocacy services, while actively seeking opportunities to partner with others and serve as ambassadors of goodwill in our community. We are a grassroots organization, and all of our services are free and open to the public.

WANT TO HELP SUPPORT OUR EFFORTS? Please consider becoming a PALMETTO PARTNER through our recurring giving program. For more information: www.palmettopartnership.org