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CIL's in TN
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About US
Services
Family Support
Services
Resources
CIL's in TN
Donate
Contact Us
T.A.R.P. Center for Independent Living
Intake Form
I am filling out this form for someone else
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Yes
No
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Indicates required field
Name of Person filling out form
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First
Last
[object Object]
Name of Person needing services
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First
Last
[object Object]
Todays Date
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Email
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Address
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Line 1
Line 2
City
State
Zip Code
Country
County of Residence
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Home Phone Number
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Cell Phone Number
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Ethnic Origin
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Hispanic/Latino
Non Hispanic
Race
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Sex
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Male
Female
Other
Date of Birth
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Do you have a significant disability?
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Yes
No
Do you have health insurance?
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Yes
No
Are you in the process of transitioning from a facility?
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Yes
No
Do you need any of the following accommodations?
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Braille Print
Digital Format
Large Print
Interpreter Services
None
Do you have a legal guardian or power of attorney (POA)?
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Yes
No
Guardian or POA Name:
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First
Last
Guardian or POA Address
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Line 1
Line 2
City
State
Zip Code
Country
Guardian or POA Best Phone Number
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Guardian or POA Email
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Are you Registered to Vote?
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Yes
No
Do you need assistance registering to Vote?
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Yes
No
Veteran?
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Yes
No
Disability Service Connected?
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Yes
No
N/A
Date of Service
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Previous Rehabilitation Services (PT, Voc Rehab, etc…):
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Other Agencies Currently Involved:
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Home Health
LIHEAP
SNAP
Mental Health Services
State Program for Blind/Visually Impaired
State Program for Deaf/Hard of Hearing
None
Other
I have the following significant disability(ies):
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Self-Identifies
Mental/Emotional
Physical
Hearing
Vision
Multiple Disabilities
Cognitive
Other
None
Primary Disability
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Secondary Disability
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Additional Comments?
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My disability(ies) substantially limit me from functioning independently in the following area (s):
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Self-Care
Mobility
Education
Employment
Housing
Other (Specify Below)
Other
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The services I am requesting will help me: (Please check all that apply)
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Improve my ability to function in my family or community.
Maintain my ability to function in my family or community.
Obtain, maintain or advance in employment.
Any request for services or equipment is subject to approval and availability.
Upon approval you will be notified.
Permission to Release/Receive Information
I give T.A.R.P. CIL permission to contact
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For the purpose of
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Releasing Information
Receiving Information
Information allowed to be shared
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The only information released or received will be regarding the Independent Living Services the consumer has requested.
The release of this information is in effect until expiration date 1 year after date signed.
I understand that this information will Be kept confidential. It Will not be discussed or released to anyone, other than who is listed on the release.
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Yes
Grievance & Conciliation Procedure
If a consumer meets any action, occurrence or attitude, either expressed or implied, by
a staff, that the consumer perceives as unfair or inequitable, he/she is expected to
discuss it with the staff person involved.
If that does not resolve the issue, the consumer may appeal in writing to the Executive
Director, T.A.R.P. Center for Independent Living (T.A.R.P. CIL), 1027 Mineral Wells
Ave. Suite 7, Paris, TN 38242. The Executive Director will meet with the consumer and
respond to the appeal within seven (7) business days.
If not satisfied, you may appeal in writing within (5) business days to the Board of
Directors, T.A.R.P. Inc, 1027 Mineral Wells Ave. Suite 7, Paris, TN 38242. A hearing
will be held, and the Board of Directors will respond to you within (10) business days.
Consumers may engage, at their own expense, a lawyer or other agent to represent
them during the appeals process. Contacts to aid consumers are available in the state
of Tennessee through: Disability Rights TN 1-800-342-1660 (TTY) 1-888-852-2852
www.disabilityrightstn.org gethelp@disabilityrightstn.org
Client Rights
T.A.R.P.’s number one goal is to partner with you to help maintain or increase your
independence. In the event of being dissatisfied with any decisions concerning the delivery or
denial of services, you have the right to appeal the decisions of the IL Specialist in accordance
with T.A.R.P.’s policy for Grievance for Consumer and Community Members. Furthermore, you
have the right to discuss any questions or problems with the
Client Assistance Program (CAP).
Disability Rights TN 1-800-342-1660 (TTY) 1-888-852-2852
www.disabilityrightstn.org gethelp@disabilityrightstn.org
TARP provides equal services to all persons without regard to race, color, religion, disability, sex, age, or national origin
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I have read and received the above information on CAP
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Yes
I give permission for TARP Center for Independent Living Grantors to view my files, if necessary.
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Yes
I certify all information is true and correct to the best of my knowledge.
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Yes
By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this form.
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I Accept
ILS Signature
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Date
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Submit