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Groups of adult program participants

Holy Childhood Referral Application

Individual’s Information

Correspondent(s) Information

Care Coordinator Information

Programs Interested In

Have you received services from Holy Childhood before?

Please indicate level of support needed for the following

Is a Behavior Support Plan or Guidelines in place?

Please be sure to send in the following for this Referral Application:

  • Most recent Life Plan
  • IPOP (if applicable)
  • Consent to release information Form
  • Most recent psychological evaluation
  • Legal Guardianship papers (if established)
  • Work Restrictions (if applicable)
  • Vocational Assessments (if applicable)
  • Proof of current Waiver enrollment
  • LCED
  • Current physical ( within 1 year )
  • Current PPD-( 2 step must be completed before a trail start date with the exception of Respite)
  • Tetanus ( within 10 years)
  • Self-Medication Assessment ( if Applicable)