Pre-Screening Application This is a Pre-Screen Application. The purpose of this Application is determine your eligibility as a Medicaid Client under our program of services.Please Check One (A Provider for Medicaid, Veteran or Private Participant):If You are already on the Medicaid Waiver ProgramIf You would like to become a Medicaid Waiver ParticipantA Veteran ParticipantA Private ParticipantA Provider forPersonal & Family Information:First Name:Last Name:Date of Birth: Address:Home Phone:City:State:Cell Phone:Zip Code:Country:Email: Caregiver Information:First Name:Last Name:Date of Birth: Address:Home Phone:City:State:Cell Phone:Zip Code:Country:Email: Services You May RequireHow many days of the week do you plan to utilize our our services or stay at our facility?Will you need our transportation service?YesNoDo you plan to participate in the food nutrition program?YesNoNAME OF RESPONSIBLE PARTY:Thank you for taking the time to fill out the Pre-Screen Application. Our Director will contact you shortly to set up an interview. If you have any question about the application or any of Reach Adult Recreational Services, please feel free to contact us at (662) 838-5555. This iframe contains the logic required to handle Ajax powered Gravity Forms.
