Applicant Information

Name:    Address: 

City:    County:    State:    Zip: 

Phone:    Email: 

Is Applicant a full-time Florida resident?  Yes  No      
If no, please provide out-of-state address and time spent in Florida information below:

Address: 

City:     State:    Zip: 

Phone:    Email: 

Applicant spends time in Florida from  (date)   to   (date)   each year

Preferred method of contact, Applicant:  Phone  Email  Mail

Gender:  Male   Female                     Age:        Date of Birth:   

Place of Birth: 

Services desired:  Adult Day Training  Supported Living  Supported Employment and Student Volunteering
                          Loveland House (Group Home)    Phase II        (check one or more) 

Applicant lives:  with both parents   with mother   with father    with other relative(s) 
                       alone     on his/her own with roommates

Parent/Guardian #1 Name:    Relationship to Applicant: 

Address:  City:   

State:    Zip:    Phone:    Email: 

Preferred method of contact, Parent/Guardian #1:  Phone  Email   Mail



Parent/Guardian #2 Name:  Relationship to Applicant: 

Address:    City:   

State:    Zip:    Phone:    Email: 

Preferred method of contact, Parent/Guardian #2:  Phone  Email   Mail

Non-Custodial Parent Name (if applicable):   

Relationship to Applicant:     Address: 

City:    State:    Zip:    Phone:    Email: 

Preferred method of contact, Non-Custodial Parent:  Phone  Email   Mail

Emergency Contact Information (other than Parents'/Guardians')

Name - Contact #1:     Phone:   

Name - Contact #2:     Phone:   

Employment Information for Parent(s)/Guardian(s):

Occupation - Parent/Guardian #1:    Retired?  Yes  No

Employer:        Current   Former

Address: 

City:    State:    Zip:    Phone: 

Occupation - Parent/Guardian #2:     Retired?  Yes  No

Employer:       Current   Former

Address: 

City:    State:    Zip:    Phone: 

Occupation, Non-Custodial Parent (if applicable):     Retired?  Yes  No

Employer:       Current   Former

Address: 

City:    State:    Zip:    Phone: 

Children & Families/Developmental Services:  Yes  No

If yes, name of Case Worker:    Address: 

City:    State:    Zip:    Phone: 

Applicant's Medical Information

Physician's Name:    Phone: 

Address: 

City:    State:    Zip:    

Dentist's Name:    Phone: 

Address: 

City:    State:    Zip:    

Other Medical Provider's Name (if applicable): 

Psychologist   Psychiatrist   Neurosurgeon   Other (please specify): 

Address: 

City:    State:    Zip:     Phone: 

Applicant's primary disability: 

Allergies (if any): 

Does Applicant use (check all that apply):  Glasses  Hearing Aid  Cane  Wheelchair  Leg Brace  Walker 

Other (please describe): 

State general health of Applicant:

Date of last physical:    Date of last psychological: 

Does Applicant have difficulty with (check all that apply, if yes):

Sitting  Walking  Talking  Hearing  Vision  Sleeping  Eating  Seizures  Bowel/Bladder problems
Temper tantrums  Withdrawal behavior  Other (please describe): 


If yes to any of the above, please explain:



Hospital preference: 

Does Applicant have private insurance?  Yes  No

If yes, Name of Insurance Company: 

Address: 

City:    State:    Zip:     Phone: 

Group Number:       Subscriber ID Number: 

Subscriber ID Number is:  Applicant's   Contractholder's

Name of Contractholder: 

Relationship of Contractholder to Applicant: 

Is Applicant Medicare eligible?  Yes  No          Medicaid?  Yes  No  

List rehabilitation centers or schools previously attended

Name:      Address: 

City:    State:    Zip:     Phone: 

Name:      Address: 

City:    State:    Zip:     Phone: 

Name:      Address: 

City:    State:    Zip:     Phone: