Apply for UnionCare Services

Person-centered residential habilitation that promotes dignity, independence, inclusion, and meaningful community living.

How the Intake Process Works

We make getting started simple and supportive. Here is what to expect after you apply.

1
Submit Application
Complete the intake application below with participant, guardian, medical, and service information.
2
Initial Review
Our team reviews the information and reaches out to confirm eligibility and next steps.
3
Assessment & Planning
We meet with the participant and family to build a person-centered support plan.
4
Begin Services
Once enrollment is complete, we coordinate the start of services and ongoing support.

UnionCare Intake Application

Application for Services

Fields marked with * are required. Submitting opens your email app addressed to our team. Please do not include sensitive documents by email; our staff will collect required documents securely during follow-up.

I. General Information

Applicant Full Name *Application Date *Address *Mailing Address, if differentApplicant Email *Applicant Phone Number *Date of Birth *Gender *Social Security Number *Medicaid Number *Healthy Connections Number *Religious Preference

Additional Information

Guardian Information

Guardian Full NameGuardian Address *Guardian Phone Number *Guardian Email *

Targeted Service Coordinator / Service Coordinator

NameAgencyPhone NumberEmailFax NumberAddress

Required Documents

Indicate which documents you can provide. Our staff will collect copies securely during follow-up.

II. Medical History

Primary DiagnosisSecondary DiagnosisCurrent Living Arrangement *Marital Status *Seizure Disorder? *Seizure TypeHow frequent are seizures?Controlled by medication?Chronic medical conditions? *Is the applicant ambulatory? *Physical disabilities or limitations? *Assistive devices? *

List chronic conditions, limitations, and assistive devicesKnown allergies, including medication allergies *Recurring illnesses *Hospitalizations and surgeries *Additional relevant medical information

Medical Providers

Primary Care Physician *

Counselor / Psychotherapy

Medication Management

Dentist

PT / OT / Speech

Specialist

III. Service HistoryHas the applicant received Developmental Disability Agency services in the past? *If yes, list previous DDA(s)

IV. Educational History

Current school or last school attended *Current Grade *Contact NameLast Grade Completed *Current Teacher *

Residential Habilitation / Supported Living

Services and Supports Requested *

Supported Living, 24-Hour SupportsHourly Residential HabilitationRepresentative Payee Supports

Requested days and times for services

Participant Rights & Responsibilities

UnionCare will inform each participant, guardian, and appropriate representative of their rights and responsibilities in a manner that promotes understanding. These rights include humane care, freedom from abuse, privacy, dignity, confidentiality, access to records, the right to choose or refuse services, community participation, grievance rights, and all other rights established by law.

Humane care and treatmentFreedom from abuse and neglectPrivacy and confidentialityCommunity participationChoice and autonomyAccess to recordsFreedom from unnecessary restraintsRight to voice grievances

I acknowledge that I have read or received an explanation of participant rights and responsibilities. *

Participant Signature & Date *Guardian Signature & Date *

Acknowledgement Receipt

I have read, understood, received a verbal explanation of, and received a written copy of personal, civil, and human rights.I have received names, addresses, and telephone numbers of protection and advocacy services in my region.I have received information about alternate services available.I have received information about risks.I have received service information and grievance procedure information.I have received HCBS information, rights, rules, standards, and qualities.

Participant / Guardian Signature *

Media Release

This optional section allows UnionCare to use participant photographs in printed materials, website, or social media. This release may expire one year from the signed date.

Do you give permission for media use?

Name *Address, City, State, ZIP *Participant Name & Date *Parent / Guardian Name & Date *

Important: Submitting opens your email app with your responses. Please avoid sending sensitive documents by email; our team will arrange secure collection of required documents during follow-up.

Apply for UnionCare Services

How the Intake Process Works

Submit Application

Initial Review

Assessment & Planning

Begin Services