CLTS kids Application – Midwest Monster's Academy

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CLTS kids Application

Midwest Monsters Academy Inc.
Non Medical Clinical Services Application Form

CLTS kids Application

Step 1 of 10

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Applicant Information

Applicant Full Name(Required)

Date of Birth(Required)

Age(Required)

Gender (optional)

Primary Language(Required)

Social Security Number (optional)

Parent / Guardian Information (if applicable)

Parent/Guardian Name(Required)

Relationship to Applicant(Required)

Phone Number(Required)

Alternate Phone(Required)

Email Address(Required)

Address & Contact Information

Address(Required)

Street Address City ZIP / Postal Code State

Best Time to Contact(Required)

Emergency Contact

Name(Required)

Relationship(Required)

Phone Number

Section Break

Referral Information

Referral Information(Required)

How did you hear about Midwest Monsters Academy Inc.?

School

Social Worker

Healthcare Provider

Family/Friend

Other

Untitled(Required)

Referring Agency/Person (if applicable)(Required)

Phone/Email(Required)

Program & Service Needs

Untitled(Required)

Support & Service Coordination

Daily Living Skills Training

Community Integration Services

Mentoring Program

Grief & Bereavement Support (Non Medical)

Health & Wellness Education

Discovery & Career Planning

Financial Management Education

Community / Competitive Integrated Employment Support

Other Services Requested

Untitled(Required)

Applicant Needs & Goals

Please briefly describe the applicant's current challenges, strengths, and goals for services:(Required)

Educational & Community Information

Current School/Program (if applicable)(Required)

Grade Level / Program Type(Required)

IEP or Support Plan (if applicable)(Required)

Yes

No

Health & Safety Information (Non Medical)

Any mobility, behavioral, or safety considerations staff should be aware of? Allergies or dietary restrictions (non medical)

Consent & Acknowledgement

I understand that Midwest Monsters Academy Inc. provides non medical clinical and community based support services only. I certify that the information provided in this application is accurate and complete to the best of my knowledge.

Applicant / Parent / Guardian Signature(Required)

Printed Name

Date

MM slash DD slash YYYY

Authorization to Communicate

I authorize Midwest Monsters Academy Inc. to communicate with the following individuals or agencies regarding services:

Signature

Date

MM slash DD slash YYYY

Join Our Community

midwest monster academy

EMAIL

midwestmonsters@myyahoo.com
midwestmonstersacademy@gmail.com

Contact Us

Phone: (414) 249-3177
Fax: (414) 249-3378,
Mobile: (414) 293-7733

EMAIL

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