Welcome, we’re glad you’re here!

Please complete the intake form with as much detail as possible.

The more information you provide, the better our program staff can get to know your adult and support their individual needs, interests, and goals.

We kindly ask that you complete every section of the form, even if you feel some information may not be relevant.

Thorough and accurate information helps us create the best possible experience for your adult.

Thank you for taking the time to complete this.

Rising Adult Intake Form

Fields marked with * are required.

Parent/Guardian First Name *

Parent/Guardian Last Name *

Parent/Guardian Email *

Parent/Guardian Phone *

Second Parent/Guardian First Name

Second Parent/Guardian Last Name

Second Parent/Guardian Email

Second Parent/Guardian Phone

Street Address *

City *

State/Province *

ZIP/Postal Code *

Participant's First Name *

Participant's Last Name *

Participant's Gender *

Participant's Birthdate *

Participant's Email

Disability Details *

Participant's Communication Ability *

Current Diagnoses *

Mobility Needs *

Allergies *

Medications *

History of Seizures *

Seizure Type and Plan (Optional)

Date of Last Seizure *

Other Medical Needs *

Sensory Sensitivities *

History of Aggressive Behavior *

Communication When in Distress *

How the Participant Communicates They Need Help *

Participant Likes *

Participant Dislikes *

Participant Goals *

Can Follow 1–2 Step Directions? *

Multi-Step Task Independence *

Eating Needs *

Toileting Needs *

Behavior Concerns *

Known Anxiety Triggers *

De-escalation Strategies *

Authorized Pickup Individuals *

Individuals Not Authorized for Pickup *

Programs to be Engaged * Select one or more programs. On a computer, hold Ctrl (Windows) or Command (Mac) to select multiple options.

Accept Conditions *

I acknowledge and agree to the applicable conditions. *

Public Photo Consent *

Support and Resources Consent *

Garden Group Consent *

Foods Not Permitted in Garden Group *

Program Ratio Agreement *

Discontinuation Disclaimer *

Additional Participant Comments

Book a Tour/Interview

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Book a Tour/Interview --

Email US

New Family Trial Period & Enrollment Disclaimer

Aggression Policy

NEW FAMILIES

Complete Intake Form.

Jessica Trevino will reach out to new families once the form is received.

Schedule a tour of our facility with Jessica. 2015 Dean Street (Unit 5), St Charles, IL 60174. Please see the map below as well.

Before your visit, please take some time to review the documents titled “New Family Trial Period & Enrollment Disclaimer” and “Aggression Policy.” These can be found at the bottom of this page.

Sign the “Aggression Policy” and “New Family Trial Period & Enrollment Disclaimer” and email it back to Jessica.

All new families are required to submit two letters of recommendation prior to or during the trial period. This is the form to the left. Letters must be from individuals familiar with the participant in a structured setting, such as a previous school, a prior program or service provider, a member of the participant’s IEP team.

If you have any questions in the meantime, please choose the “Email Us” option below.

Welcome, we’re glad you’re here!

Rising Adult Intake Form

Book a Tour/Interview

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Book a Tour/Interview --

NEW FAMILIES

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Program Location: 2015 Dean Street, St. Charles, IL