Intake Form | NeuSpark PDS

1—Which program are you interested in?

Not sure which fits best? Choose your best guess—our team will help confirm the right fit during your screening.

Site-Based Day Programs Skill-building and activities at one of our program locations. Day Habilitation Without Walls Community-based day services (DHWOW). Residential Services Housing and everyday living support. Not sure yet I'd like to talk it through with someone first.

How soon are you hoping to start? *

How did you hear about NeuSpark PDS? (optional)

2—Who's filling this out?

This helps us know who to follow up with.

Your First Name *

Your Last Name *

Relationship to Person *

Phone Number *

Email Address *

Best Time to Reach You (optional)

3—About the person supported

The person who will be joining the program.

Middle Name (optional)

First Name *

Last Name *

TABS ID# (if known)

Date of Birth *

Medicaid ID# (if known)

Phone Number (if applicable)

Home Address *

Preferred language

4—Emergency contact

Someone we can reach if we're unable to contact you directly.

Name *

Relationship *

Emergency Contact Phone Number *

6—Behavioral support needs

This helps our team plan the right support. Anything sensitive or complex is always welcome to be discussed privately with our intake team rather than in writing here.

Please check anything that applies: (optional)

Physically aggressive toward others Property destruction Verbal outbursts Self-injurious behavior Elopement / wandering Anxiety / withdrawal Fears or phobias

Other

Anything you'd like to add? (optional)

To finish setting up your intake, we'll schedule an in-person meeting with you and your family member. When you come in, please bring along essential documents such as their birth certificate, Social Security card, medical history, and any items listed on our Intake Page.

7—Consent & signature

A few acknowledgments before we submit your information.

I understand that NeuSpark PDS will use the information I provide here to determine program eligibility and to prepare for a screening visit. I understand I will receive a copy of NeuSpark PDS's Notice of Privacy Practices, and that I may request a paper copy, ask questions, or request additional privacy protections at any time.

I acknowledge the above and consent to NeuSpark PDS collecting this information for intake purposes. I agree to be contacted by phone or email regarding this intake request.

Typed Signature (Full Name) *

Date *

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