Members Intake Form MembersMember Intake FormParent/Guardian Name* First Last If you are the member, simply enter your nameAddress* Street Address City State ZIP Phone Number*Email* County* West Maricopa North Maricopa East Maricopa South Maricopa Name of Individual Receiving Services* First Last Age*HiddenISP GoalsHiddenDescribe Present Levels:HiddenBehavioralHiddenBehavioralHiddenEducationalHiddenSocialHiddenEmotionalService Coordinator / Case Manager:HiddenDoes this individual share the same address as the Parent/Guardian?* Yes NoHiddenIf not, what is the address of the individual?* Street Address City State ZIP Do you have a current ISP or written service agreement?* Yes NoDoes this individual have an intervention plan for dangerous behaviors?* Yes NoHiddenIf so, what is the intervention plan?*HiddenCare History Autism Oppositional Defiance Disorder (ODD) Down's Syndrome Cerebral Palsy Intellectual Delay Disability (IDD) Post-Traumatic Stress Disorder (PTSD) Obsessive Compulsive Disorder (OCD) Seizures Abuse In Past Attention-Deficit / Hyperactivity Disorder (ADHD) Self-Harm or Others Dangerous Behaviors Verbal Ambulatory Bowel Issues / IncontinenceCase Manager Contact InformationCase Manager Name First Last Case Manager Phone NumberEmail How many hours per month are allotted for services?*Please designate if: Attendant Care Habilitation Care Resite/Relief CareMay we contact your Case Manager/ Service Coordinator? Yes NoCase Manager NotesDo you have a friend or family member that you would like to be the DSW for your support services?By submitting this form I understand that I am authorizing KIDS AZ to contact me about services.CommentsThis field is for validation purposes and should be left unchanged.