Family Support Services Application

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

Section I: Demographic Information

Date of Application:

Individual Name:

Social Security Number:

Gender:

Male

Female

DOB:

Age:

Race (optional):

American Indian or Alaskan Native

Asian or Pacific Islander

African American

Caucasian/Anglo

Multi-Racial/Ethnic Group

Other:

Ethnicity (optional):

Not Hispanic

Hispanic or Latino

Insurance Information - Private:

Public (Medicaid) #:

Family member/Guardian Name:

Relationship to the Individual:

Legal Guardian of the Individual:

Mailing Address:

County of Residence:

Phone:

City, State, Zip:

Email:

Section II: Diagnostic Information

Developmental Disability Diagnosis:

Check which of the following disability categories is most relevant to the identified individual:

Autism Spectrum Disorder

Neurological Impairment (Prior to age 22)

Intellectual Disability

Developmental Delay (0 – 8)

Cerebral Palsy

Traumatic Brain Injury (Prior to age 22)

Muscular Dystrophy

Other:

Age at Time of Diagnosis:

Supporting Documentation:

Documentation of Diagnosis

Individual Education Plan (IEP)

Other:

Section III: Current Service Information

Please check all sources of the individual’s current natural support network:

Section IV: Services Needs/Requests

Are the services/goods identified above accessible through other sources?

Yes

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

Yes

Describe the benefit to the family if the services and goods above were funded:

DBHDD I&E Assessment:

Social Security Disability Determination (SS):

School IEP:

Medical Verification:

Psychological Evaluation:

Other:

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.

Individual’s Signature (If over 18 years of age):

Individual’s Printed Name:

Parent/Legal Guardian’s Signature (If under the age of 18):

Parent/Guardian’s Printed Name:

Section VI: Eligibility Review and Determination

Individual’s Name:

Date Completed Application Received:

Disposition for Family Support:

Eligible For Family Support Services (Forward Application and Supporting Documents to the Regional RSA)

Ineligible For Family Support Services

Provider Agency - Name:

Provider Staff - Name:

Title:

Contact Number:

E-Mail Address:

Provider Staff - Signature:

Date:

For Regional Office Use Only

Date Application Received:

Date Application Reviewed:

Disposition for Family Support:

Yes Eligible Status Verified

No - State the reason:

Provider:

Date of Notification:

Regional Staff’s Name:

Title:

Regional Staff’s Signature:

Regional Signature Date

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