HUD Application

Name(Required)

Age(Required)

Birth Date(Required)

Sex(Required)

Phone

Address(Required)

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

Program/Service Requested

Person and/or Agency Making Referral

Do you currently have Medicaid?

If no, are you eligible?

Are you currently enrolled in any Arc programs?

If yes, which programs?

Diagnosis or Disability

Parent or Guardian

First Last

Parent/Guardian Phone

Parent/Guardian Address

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

Race/Ethnicity of the Head of Household

Was any household member (who does not have a Social Security Number) 62 years of age or older as of January 31, 2010?(Required)

If yes, was their initial determination of eligibility done prior to January 31, 2010?(Required)

Please list the name(s) of the individual(s) to whom the above applies

Are you or any members of the household subject to a lifetime registration requirement under a state sex offender registration program?(Required)

If yes, please explain(Required)

Please list the household members and all states in which the member has resided(Required)

Emergency Contact #1

First Last

Emergency Contact #1 Phone

Emergency Contact #2

First Last

Emergency Contact #2 Phone

Name of Service Coordinator

Service Coordinator Phone Number

Name of Primary Physician

Primary Physician Phone Number

Name of Psychiatrist

Psychiatrist Phone Number

Name of Dentist

Dentist Phone Number

Name of Other Physicians

Current Medications (please list)

Known Allergies (please list)

Specific Medical Problems or Concerns

Strengths of Individual

Abilities of Individual

Likes/Hobbies of Individual

Dislikes of Individual

Desired outcomes and expectations to be accomplished from this program?

Does the individual use or need any adaptive equipment?

If yes, what?

Does the individual have any specific behavior problems?

If yes, please describe.

Current Day program or job:

Days/hours of this program or job:

Any other information that would be of assistance in serving the individual?

Does the individual have a need for an accessible apartment?

Method of rent payment (private insurance, SSI, employment wages, etc.)

Enter your name in the textbox below to serve as your signature.(Required)

By checking this box, this verifies that you have answered the questions to the best of your knowledge.(Required)

Yes, I answered to the best of my ability

No, I did not answer to the best of my ability

Please add today's date(Required)

HUD Application

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ADMINISTRATIVE OFFICE

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