BTW Program Inquiry Form

To begin the inquiry process for inclusion in our Bridges to Work vocational program, please complete this form and submit for review. Our program director will contact you to discuss next steps.

* Signifies that a response is required.

Full Name of Applicant*

First Last

Parent/Primary Guardian Name*

First Last

Parent/Primary Guardian Email*

Parent/Primary Guardian Mobile Phone*

Parent/Primary Guardian Home Address*

Street Address City State ZIP Code

Does your loved one live with you?*

Yes
No

Participant Residential Address

Street Address City State ZIP Code

Reason for Inquiry*

Turning 22
Program Transfer
Looking for a Program

Date Turning 22

Current/Former Program

Program Payment Type*

Please select all that apply

DDS Funding (All or Partial)
Self Pay (All or Partial)

DDS Information

DDS Service Coordinator

Does your loved one have a DDS Coordinator?

Yes
No

DDS Area Office

DDS Service Coordinator Name

DDS Coordinator Phone

Funding & Utilization of Services

Anticipated DDS 'Days Funded' or Self Pay BTW Services Required

Day(s) Requesting to Attend Program

Monday
Tuesday
Wednesday
Thursday
Friday

Current Status and Services

Educational Services*

High School
N/A
Other

Other Educational Services

Adult Services*

Community Based Day Services
Day Habilitation
Employment Services
N/A

Program Name

Provider

Clinical Services*

ABA Therapy
Counseling
Occupational Therapy
Physical Therapy
Psychiatry
Speech Therapy
N/A

Medication Administration*

Will your loved one require medication during program hours?

Yes
No

Medical Services

Morning Medication
Afternoon Medication
Evening Medication
Visiting Nurses Services

Personal Profile

Please note that this forms data will be encrypted prior to submission.

Communication Profile*

Fully Conversational
Limited Verbal
Non-Verbal
Uses Sign Language
Communication Device

Maladaptive Behavior*

Inappropriate Verbal
Aggression
Self-Injury
Sexualized Behavior
Property Destruction
Perseveration
No Maladaptive Behavior

Dining*

Food Requirements

Cut or Chopped
Ground or Pureed
Fluids Only

Personal Care: Restroom*

Independent
Requires Supervision
Requires Physical Support
Requires Physical Transfer

Personal Care: Hands & Face*

Independent
Requires Supervision
Requires Physical Support

Durable Medical Equipment*

Does your loved one require any type of medical equipment?

AFO's
Crutches
Walker
Wheelchair (manual)
Wheelchair (power)
No Equipment Required

Additional Program Services

Transportation and Extended Day Services are offered at an additional cost and are private pay only. DDS does not cover these expenses. Please acknowledge that you understand below.

Acknowledgement of Costs*

I understand that I am personally responsible for transportation and extended day services fees.

Yes I acknowledge costs
We will not require these services

Transportation

Please select all of the days which your loved one will require transportation. Please note that there are no transportation services after 2pm.

Monday
Tuesday
Wednesday
Thursday
Friday

Extended Day Services

Support services post-program hours are offered M-F 2p-4p (DDS Funded) 4p-5p (Private Pay). Please note that Extended Day Services are ONLY available to BTW participants.

Monday
Tuesday
Wednesday
Thursday
Friday

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Bridges to Work Family Inquiry Form

DDS Information

Funding & Utilization of Services

Current Status and Services

Personal Profile

Additional Program Services

About Us

Our Programs

Support & Contributions

Events & Inquiries