New Consumer Intake Form
Email address *
Ability Matters is an I/O, Level 1 waiver, and Autism Scholarship Program provider agency that emphasizes community inclusion and serves individuals with disabilities in Franklin and surrounding counties. With an individual program for each client, Ability Matters believes that all individuals can contribute to their community and reap many benefits from community involvement. Employing care providers with specialized training and experience, Ability Matters is able to accommodate clients with a variety of social and behavioral needs. Ability Matter’s CEO, Dr. Kristyn Miller, has a Ph.D. in Applied Behavior Analysis and Special Education, allowing her to implement programming for a wide range of diverse clients. For more information, please visit our website at www.abilitymattersohio.com or email info@abilitymattersohio.com.
Individual's name *
Date of birth *
MM
/
DD
/
YYYY
If the individual is younger than 22, what is their graduation status? *
The purpose of this question is to determine eligibility for an Autism Scholarship
Waiver type *
Required
Services you are seeking *
Required
Is the individual interested in Independent Supported Living? *
Does the individual have an ISP or IEP? *
Required
What days and times are you requesting service? *
7a-11a or 7a-3pm
3p-7p or 3p-11p
11p-7a
n/a
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
I don't know yet
What is the ideal start date for services for the individual? *
Please keep in mind that we usually have at least a 30-day preparation period between initial consultation and beginning services.
Individual's diagnosis *
Next
Never submit passwords through Google Forms.
This form was created inside of Ability Matters.