Groups of adult program participants

Holy Childhood Referral Application

Individual’s Information

Correspondent(s) Information

Does the individual have a Legal Guardian

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)

 

Note: For All Referrals - please remit current copies of the following to nzelesnikar@holychildhood.org:

Insurance Cards - Medicaid Benefit Card and all other insurances the person is covered by.

Most recent psychological evaluation and social evaluation (MSC).

Current Life Plan (or addendum done by Care Coordinator) listing "Article 16 Clinic, Holy Childhood" to providers section required on approval before start of services.

         Adult Program Forms

For an Adult Programs Referral Form, please contact: Nate Zelesnikar

For an Article 16 Clinic Referral Form, please contact: Heather Smith

Questions?  Contact Adult Programs & Services Administrative Assistant: Jessica Stratton