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Our Guiding Principles Are Integrity, Inclusion & Self Determination

We provide a wide range of services for those with disabilities and their families. We will reach out to you and provide the information you need to make a reasoned decision about a loved one.

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SUBJECT

FIRST NAME *

LAST NAME *

EMAIL ADDRESS *

PHONE NUMBER

Which position are you interested in applying for? (If unsure enter General)

Are you over the age of 18?

Are you legally able to work in the USA?

Do you have a reliable means of transportation & a valid driver's license?

Were you referred by a member of the PACC staff? If so, who?

(Optional) Attach a cover letter in PDF or Word format.

(Optional) Attach your resume in PDF or Word format.

Additional Comments:

Comments:

Client Information (person referred for service):

First Name *

Last Name*

Address *

City*

State*

Zip Code*

Phone*

Email*

Date of Birth*

If other, please specify

Is there a legal guardian?*
YesNo

Legal Guardian Information:

First Name *

Last Name*

Address *

City*

State*

Zip Code*

Phone*

Email*

Nature of Service Requested (list all that apply):
Risk Screening for Problematic Sexual Behaviors (sexual offender)Intensive Consult (problematic sexual behaviors or female offender)Ongoing Behavioral Support/ConsultationFunctional Behavior Assessment (FBA)Sexual Consent Screening

Funding Source (list all that apply): Please note all funding sources must be verified.
ODP Consolidated WaiverResidential ContractCommunity Living WaiverBase FundsPrivate Pay

List funding source county, if applicable

Information On Referred Source (person making the referral):

Date*

First Name *

Last Name*

Address *

City*

State*

Zip Code*

Phone*

Email*

County of Residence*

Support Coordinator Information:

Name*

Phone*

Email*

Reason for Referral/Describe Problematic Behaviors or Symptoms:

Referral Date*

Referral Urgent *
YesNo

First Name *

Last Name *

DOB *

Address *

City *

State *

Zip Code *

Phone *

Waiver Type *

POA/Caregiver *

POA/Caregiver Phone *

Support Co-ordinator Name *

Support Co-ordinator Phone *

POA/Caregiver is preferred for initial contact *
YesNo

Information On Referral Source (person making the referral):

First Name *

Last Name*

Address *

City*

State*

Zip Code*

Phone*

Email

Credentials

Relevant Medical History and Background Info:

Reason for referral *

Health Issues (diagnosis/functional complaints) *

Chronic Condition

Primary Care Physician Name *

Primary Care Physician Phone *

Client and/or POA/Caregiver, SC is aware and consents to referral: *
YesNo

Are you aware of any safety concerns for the clinician entering this client’s home environment? *
YesNo

Our Guiding Principles Are Integrity, Inclusion & Self Determination

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