Follow the steps to accurately complete the application.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred PDF viewer.
2. Begin by entering the program name, location, phone, fax, and contact person information. Ensure accuracy as this will help in the follow-up process.
3. In the section for today’s date, fill in the current date. If you know your discharge date, include it as well.
4. Enter the dates of service starting with the admission date. This information is essential for processing your application.
5. Complete the client information fields by entering your full name, date of birth, any aliases, and personal medical identifier number (PMI#).
6. Fill out your marital status, social security number (SS#), sex, race, and primary language. If you identify as Hispanic, indicate 'yes' or 'no'.
7. Provide your street address, city, county, state, and zip code. Include your phone number and specify whether the address is a private residence. If it is not, provide a description of the alternative living situation.
8. If you lived in a facility prior to entering, provide that information. If you were homeless, describe where you stayed and for how long.
9. Indicate if you have a county case manager or social worker. If yes, specify which county they belong to.
10. Next, provide household size by including the number of adults and the number of children living with you under age 18 that you have parented or adopted.
11. State your total household size and annual household gross income before taxes. If applicable, subtract any court-ordered child support from this total.
12. Select your income source from the options given, such as job, SSDI, SSI, general assistance, and others. Provide the name and address of your employer if applicable.
13. Fill out the insurance information section. This helps determine your funding eligibility.
14. Finalize your application by signing and dating the client signature section followed by the staff signature and date section.
15. Once the form is complete, save your changes, download a copy, print it for your records, or share it as needed.

Complete your application online today to take the next steps towards receiving necessary services.