Request for Placement Information

Please complete the short form below and if possible, attach the individual’s ISP. This helps us understand the individual’s needs and if NCFL could be the right fit. It will also officially place someone on our wait list for day program, residential placement, or both. We will reach out to schedule a tour and/or informal Meet and Greet. Thank you!

Individual's Information

First Name

Last Name

Date of Birth

Gender

Individual's Tier Level (if known)

Placement Type

Supports/CCP (if known)

Listed on the individual’s ISP.

Does this individual require medical supports?

Yes

Not Sure

Current Placement Information

Current Placement Type

Agency Name (if applicable)

Current Support Coordinator Agency

Contact Person

Contact Phone

Email Address

Guardian Information

First Name

Last Name

Relationship to Individual

Mobile Number

Home Number

Email Address

Street Address

City

State

Zip

Additional Guardian Information (if applicable)

First Name

Last Name

Relationship to Individual

Mobile Number

Home Number

Email Address

Street Address

City

State

Zip

Documents

Current ISP or IEP (if available)

Reason for Seeking Placement

How did you hear about NCFL?

Person Completing This Form

Relationship to Individual

First Name

Last Name

Email Address