As an individual in need of independent living services or the parent/legal guardian of a program candidate, I am requesting consideration for the services of Presbyterian Homes & Family Services, Inc. to assist me/us in meeting the needs of .

The information provided shall be accurate to the best of my/our knowledge and accurately reflect the needs of the candidate for services. Throughout the application process and placement, I will make every effort to cooperate, assist, and participate in the application, planning and services that may be provided.

Why are you requesting Independent Living Services?

What specific physical needs does this participant present?

What educational needs does this participant have?

What mental health, emotional and/or psychological needs does this participant present?

Why do you feel this facility is suitable?

Does the admission of this participant present any significant risk to him/her or others?

Please specify the independent living/life skills that need to be developed?

Your assistance and support throughout the application process are required so that Presbyterian Homes & Family Services, Inc. can secure documentation, information and records from various resources that will assists in determining the need for placement, appropriateness of placement and for the development of a plan for care and treatment.