Apply For Services - RISE Community Services

Service Participant Application

Please review and complete the following information

Name*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code

Social Security #*

Date Of Birth*

Are You Your Own Guardian?*

Yes
No

Guardian’s Name*

First Last

Best Person to Contact*

First Last

Email*

Phone*

How can RISE Community Services support you in achieving your perfect life?

Check all that apply:

Employment

Developing career plan
Volunteerism to gain job experience
Focusing on tasks
Responding appropriately to supervisors and coworkers
Following directions
Work attire and personal hygiene

Daily living skills

Cooking
Home maintenance & cleaning
Budgeting

Community Inclusion

Recreational activities
Identifying Community Supports

On What Days Are You Available To Receive Support?*

Check all that apply:

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

What Is The Best Time Of Day For You To Receive Support?*

AM
PM
Either AM or PM

Do You Have Reliable Transportation?*

Yes
No

Do You Have A Targeted Case Manager (TCM) Through Johnson County Board Of Services (JCBS)?*

Yes
No

TCM Name*

What Funding Resource Do You Have For Potential Services?*

Medicaid waiver - DMH (Partnership for Hope, Community Support, Comprehensive)
Autism Project waiver - DMH
Self-pay
No funding resource

Documentation is required from a professional medical doctor or psychiatrist to verify diagnosis. Please provide any additional records (e.g. medical and/or psychological testing, hospitalizations, social history, and education) to help determine service placement.

Date Disability Began*

Date Of Last Medical Exam*

Have You Participated In Vocational Rehabilitation?*

Individuals under the age of 25 that are interested in employment or employment services with RISE, MUST exhaust stated funded services through Vocational Rehabilitation.

Yes
No

Vocational Rehabilitation Denial Letter

If you have attempted to or have utilized Vocational Rehabilitation and were deemed ineligible for services, please include denial letter from Vocational Rehabilitation with application.

Max. file size: 50 MB.

Employment History

Provide the following information for your past employers or volunteer activities, starting with the most recent.

Employer*

Phone*

Job Title*

Supervisor Name And Title*

Summary Of The Type Of Work Performed:*

Reason For Leaving:*

Start Date*

End Date*

Hourly Rate*