The Arc requires completion of ALL of the following information for individuals requesting consideration for Arc services. The information provided will be kept confidential in accordance with Federal and State Confidentiality Laws and HIPPA requirements.

Referral Information
1 = None; 2 = Slight; 4 = Moderate; 6 = Pronounced; 8 = Problematic; 10 = Extreme
Referred by:
*All HCBS Waiver Referrals must be accompanied by a copy of the Current Service Plan, Social History and the Functional Assessment/SIS to be processed.
If you are unsure of these services, you can obtain a description online at or you may leave this question blank.
Guardian Information

Referrals are processed within 5 business days of receipt. To access services, an intake must be conducted with the individual. Please list the day(s) and time(s) that work best for the individual, his/her guardian/caregiver, and any other parties who will be present at the intake.

I hereby acknowledge that all information in this document is accurate to the best of my knowledge. I understand that I am required to notify The Arc in writing of any changes to this document.

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