Please fill out the following information and you will be contacted by a Rensselaer ARC Enrollment Specialist.
Name
:
Date of Birth
:
County of Residence:
Phone number
:
(Best way to reach you between 8am-4pm)
Services:
(Please check all that apply)
Planning
Residential Services
Group Day Hab/Individual Day Hab
Community Inclusion
Supported Employment
Service Coordination
Out of Home Respite
Family Support Services (Recreation, Respite, Guardianship, Reimbursement)
Transition Services
Form Completed by:
Parent
Medicaid Service Coordinator
Social Worker
Other
Additional Comments
: