Client Intake Form Client Intake Form Client Intake Form * Indicates Required Field Client’s Name * Client's Name First First Last Last Client’s Email Client’s Primary Phone * Work Phone Client’s Address * Client's Address Client's Address Client's Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Birth Date * Race * Not selectedBlack/African AmericanAmerican Indian or Alaska NativeHispanic/LatinxNative American/Pacific IslanderWhiteAsianPrefer Not to Answer Ethnicity * Not selectedHispanic/LatinoNot Hispanic/LatinoPrefer Not to Answer Gender Identity * Not SelectedAgenderBigenderFemaleGender fluidGenderqueerMaleTransgender f/mTransgender m/fPrefer Not to AnswerOther Gender Identity Pronouns * Not selectedHe/Him/HisShe/Her/HersThey/Them/TheirsPrefer Not to AnswerOther Pronouns Is the client 18 years or older? * YesNoPrefer not to answer Current Living Arrangements * I rent an apartmentI own my own homeI live with a relative or a friendI live in a nursing homeII live in a rehabilitation facilityOther Current Living Arrangements Is the client a registered voter? * Yes No Prefer not to answer Please specify disability and check all that apply. * Absence of Extremities Acquired Brain Injury (Stroke, Aneurysm, Tumor, Infection, Alcohol/Drug Abuse, Toxic Injury, Metabolic Injury) ADD/ADHD AIDS/HIV Positive Autism Autoimmune (Lupus, Thyroid, ALS, etc., Non-AIDS/HIV) Blindness Cancer Cerebral Palsy Deaf-Blind Deafness Diabetes Digestive Disorders (Chronic Pancreatitis, Esophageal Stricture, Fistulae, Chronic Liver, etc.) Epilepsy Genitourinary Conditions (Kidney, Prostate) Hearing Impaired (Not Deaf) Heart and Other Circulatory (Cardiovascular) Intellectual Disability Learning Disability Mental Illness Multiple Sclerosis Muscular Dystrophy Muscular/Skeletal Impairment (Arthritis, Fibromyalgia, Osteogenesis Imperfecta, Osteomyelitis, etc.) Neurological Disorders (Brain Tumors, Convulsive Disorders, Parkinson’s, etc.) None Orthopedic Impairment (Spinal Cord Injury, Paraplegia, Quadriplegia, Back Problems, etc.) Physical/Orthopedic Respiratory Impairment (Emphysema, Asthma, Pulmonary Hypertension, Cystic Fibrosis, etc.) Skin Conditions Speech Impairment Spina Bifida Substance Abuse (Alcohol, Drugs) Tourette Syndrome Traumatic Brain Injury Unknown Visual Impairment (not blind) Other Disability (Please Specify)Other Disability (Please Specify) Other Emotional/Behavior (Please Specify) Other Emotional/Behavior (Please Specify) Are you contacting us about an education matter? * Yes No Name of School District * Please select any of the following types of benefits/public supports you receive * All Kids (State CHIP Program)Elligible for Waiver supports (ID, E&D, etc.) but on waitling listMedicaidMedicaid & SSIMedicaid & SSDINonePrivate InsuranceReceiving Alabama Community Transition (ACT) waiverReceiving Elderly & Disabled (E&D) waiverReceiving HIV/AIDS waiverReceiving Intellectual Disabilities (I&D) waiverReceiving Living at Home waiverReceiving State of Alabama Independent waiverReceiving Technology Assisted waiver for AdultsSSDISSITRICAREOther Please select any of the following types of benefits/public supports you receive Primary Contact’s Name * Primary Contact's Name First First Last Last Primary Contact’s Email * Primary Contact’s Phone Number * Relationship to the Client * Primary Contact’s Address * Primary Contact's Address Primary Contact's Address Primary Contact's Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Would you like to be added to the ADAP Mailing List? * Yes No Describe the problem that prompted you to contact ADAP: * What steps have you taken to resolve this issue on your own? * Is there a deadline associated with the issue you’re contacting us about? * Yes No Deadline Explanation: * Please describe any accommodations you may need to help with the intake process: * This intake form does not create an attorney client relationship between ADAP and client. * Agreed In accepting this intake, ADAP is not agreeing to represent the client in any legal matter. * Agreed ADAP is not responsible for ensuring that any identified requirement or deadline is met. * Agreed ADAP will evaluate my request for legal help in compliance within it’s Eligibility Criteria and Current Goals & Priorities. * Agreed ADAP will contact me to set up a telephone intake appointment to conduct a full intake regarding my concern. * Agreed **Private Duty Nursing Rule under EPSDT:** We are aware of the planned enforcement of Ala. Admin. Code r. 560-X-11-.14(2)(k)(10), which states that private duty nursing (PDN) services may not be provided by a recipient’s spouse, parent, guardian, foster parent, or anyone legally responsible for the recipient who resides with the recipient. This rule impacts only EPSDT providers, which is the service that provides the majority of Medicaid-funded private duty nursing services for children under the age of 21. This rule has been in place for several years, though enforcement was not prioritized until recently. We encourage those impacted by this enforcement to contact Medicaid and their local legislators to inform them of the rule affects them and those they care for. If you would like to have an intake with ADAP to provide information about your experience and learn more about how enforcement of this rule impacts your family, please note that in the “Describe the problem” section above. Submit If you are human, leave this field blank. This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.