What is Autism?
Stanly County Operations
Wilmington Operations
Carolina Farms
Therapeutic Riding Program
MORROW VALLEY FARMSTEAD
Contact
Creative Arts
COVID-19 Forms
GHA Autism Supports
Albemarle, NC | Wilmington, NC
About Us
Meet Our Management Team
Our History
Board of Directors
Strategic Plan
News & Events
Careers
Services
Services Overview
How to Access Our Services
Quality Management
Accreditation
Organizational Processes
Satisfaction Surveys
Cultural Diversity
Testimonials
Family Support Network
General Information
Resources
Links
In the News
Tours
CULTURAL DIVERSITY
Services Application
Application for Services
0% Complete
1 of 10
If you are human, leave this field blank.
Please select service(s) being requested:
Residential
Day Services
Supported Employment
Specialized Case Consultative Services
Identifying Information
Individual's First Name
*
First
Individual's Middle Name
*
Middle
Individual's Last Name
*
Last
Individual's Preferred Name
*
Preferred
Gender
Male
Female
Other
Gender
Date of Birth
*
Social Security #
*
Medicaid #
Medicaid County of Origin
If applicable, Medicare #
If applicable, Prescription Drug Plan
If applicable, any additional third party coverage
List all services currently receiving
*
Innovations Waiver Funding?
Yes
No
Managed Care Organization (MCO) associated with
List all previous services this individual has received:
Type of Service and Location
Length services were provided
Reason(s) services were discontinued
Service Type/Location
Length services were provided
Reason(s) services were discontinued
Service Type/Location
Length services were provided
Reason(s) services were discontinued
Next
Translate this page into another language using Google Translate .
We are a 501(c)3 non-profit organization.