Demographic Information
This is for the individual on the waiver who is seeking services.
Name of Individual on Waiver
If this individual is emancipated, but requires assistance completing forms we will need permission from the consumer permitting us to correspond with a third party (e.g. parents). Please complete the portion below with the consumer and have the consumer sign. Not completing this portion may cause delays in starting services. If this consumer is emmancipated and will complete forms and correspond with us themselves this portion can be left blank. I, , give Swan Garden Home Services LLC permission to correspond and coordinate with in order to begin services with Swan Garden Home Services LLC. This includes permitting the above named individual to correspond with Swan Garden Home Services LLC by email, in-person, and phone regarding my services and allowing this individual to complete necessary forms on my behalf.
Clear
Address
Primary Contact Information
Parent/Guardian or Self
Please be sure to enter an email that is checked frequently as we will send important updates and forms electronically to the email provided here. We recommend you add info@swangardenllc.com to your contacts so emails do not go to a Junk/Spam folder.
Services Selection
We have select therapy openings listed on our website in detail. Please refer to these listings to determine if your availability matches.
Waiver Team Member Information
A pick list is the form your case manager will present to you to review available companies in your area. You will initial and sign this form and return to your case manager to select Swan Garden Home Services LLC and authorize your case manager to send us information about this consumer (it is not a guarantee of services).
Behavior Consultant Name
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