LifeMAP Application Form

All required fields are marked with an asterisk (*).

I. Applicant Information

First Name *

Middle Initial

Last Name *

Date of Birth

Street Address *

City *

State *

Zip Code *

Home Phone Number *
Cell Phone Number

E-mail Address *

Are you currently working? Yes   No
Are you currently in school? Yes   No
Are you currently: Other (please specify):
Are you living:
With parents
On your own
With spouse
Other (please specify):
Do you drive? Yes   No
Do you have access to a car? Yes   No
Gender Male   Female
Ethnicity
White (non-Hispanic)
Black (non-Hispanic)
Hispanic or Latino
Native American or
Alaskan Native
Asian or Pacific Islander
Other (please specify):
What is your annual income?
Does your family or someone else help supplement your income? Yes   No
If YES, indicate approximate annual amount:

II. Diagnosis & Treatment

Please indicate present diagnosis:
Asperger Syndrome
High Functioning Autism
Pervasive Developmental Disorder - Not Otherwise Specified
Other (please specify):
Age at Diagnosis
Diagnosis made by
Street Address
City
State
Zip Code
Phone Number
May we speak with your doctor? Yes   No
Please check off any benefits/services you are receiving:
SSI
Common Health
MRC
Mass Health
SSDI
DDS (DMR)
DMH
Other (please specify):
Are you working with other professionals such as a therapist, coach, case manager, speech therapist, etc? Yes   No
If YES, please indicate the setting:
Group
Individual
If YES, please indicate name(s) and specialty:
First Name
Last Name
Specialty
First Name
Last Name
Specialty
Do you have a Primary Care physician? Yes   No
Date of your last Primary Care appointment?

III. Goals

Name 1 or 2 things you would like assistance with:
(setting up systems to pay bills, managing appointments, organizing living space, accessing social opportunities, filling out forms, etc.)
1.
2.

IV. Special Interests

Please list any and all of your current special interests.

V. History

(Conviction will not disqualify any applicant from participating in this program.)

Have you ever been convicted of a felony? Yes   No
If YES, explain the number of convictions, nature of the offense(s) and how recently such offense(s) was/were committed;

VI. Statement of Truth

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not accepting me to participate or for immediate termination of participation in this program. I authorize the verification of any or all information listed above.

* Please check here if you agree to these terms.

Full Name
Date