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Questionnaire for Day Program Enrollment

Thank you for your interest in Rehoboth Acres' Day Program. To ensure we provide the best care and support for your loved one, please complete the following questionnaire with as much detail as possible. Alternatively, you can download a PDF version and submit via email at rehobothacresetx@gmail.com.

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Parent/Guardian Information

Full Name *

Relationship to Applicant *

Cell Phone # *

Work Phone #

Email *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Applicant Information

Full Name *

Date of Birth *

YYYY

Age *

Gender *MaleFemale

Primary Diagnosis *

Secondary Diagnoses (if applicable)

Health & Medical Information

Does the applicant have any significant health concerns? *YesNo

Please describe. *

MedicationsPlease list all prescribed and over-the-counter medications, including dosages and schedules.

Does the applicant have any allergies? *YesNo

Please describe. *

Does the applicant require assistance with mobility? *YesNo

Please describe. *

Education & Development

Has the applicant attended special education programs? *YesNo

Please provide details (school, program type, years attended). *

What life skills is the applicant currently working on? *

Does the applicant require assistance with communication? *YesNo

Please describe. *school, program type, years attended, etc.

Government Assistance & Support Services

Does the applicant receive any government assistance?Check all that apply.SSI (Supplemental Security Income)SSDI (Social Security Disability Insurance)MedicaidMedicareWaiver Program (specify below)Other (specify below)

Please specify. *

Is the applicant currently receiving services from other programs or agencies? *YesNo

Please list all. *

Interest in Rehoboth Acres Day Program

Our Day Program offers both full-time and part-time options. Select which you are most interested in. *Full-Time Day ProgramPart-Time Day Program

Why are you interested in enrolling your loved one in our day program? *

What specific expectations do you have for our facility and staff? *

What challenges do you hope this program will help to address?

Additional Comments

Is there any other information you want us to know about your young adult?

Sign and Finish

Legal Notice *

Rehoboth Acres operates as a private pay entity. Applicants' acceptance will be determined on a case-by-case basis. While all services require private payment, we are committed to considering each applicant’s financial status and will work individually with them to explore available options for service provision. Acceptance and any financial arrangements are solely at the discretion of Rehoboth Acres and are subject to review.

Signature *

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rehobothacresetx@gmail.com

1523 Colony Circle | Longview Tx 75604

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