Ardmore Admission Form | ArdmoreEnterprises 2

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Ardmore Admissions Form
Welcome to Ardmore!

Please complete the form below to begin the process of receiving services from Ardmore. Our Admissions team will review your submission and reach out to you to discuss how we can best support you or your loved one.

Person Applying:

First name*

Last name*

Birthday*

Month

Day

Year

Family Member or Support Contact (if applicable)

First name *

Last name*

Relationship to Applicant*

Phone*

Contact Information:

Email address*

Phone*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Primary Caregiver or Support Contact

(if different from above)

First name

Last name

Relationship

Phone

Current Living Situation:

Multi choice*

At Home

Residential Facility

Other

Programs of Interest (select all that apply)

Multi choice*

Group Homes and Residential Services

Housing Support

Personal Supports

Meaningful Day Programs

Customized Employment Services

Additional Needs or Requests:

Please describe any specific support needs, medical conditions, or accommodations required.

Medicaid Eligibility:

Is the individual eligible for Medicaid services?*

Yes. Please provide your Medicaid ID number below.

No

Not sure

Medicaid ID number:

CCS Contact Information:

Please provide the contact information for your Community Support Services (CCS) provider (if applicable).

CCS Provider Name:

CCS Contact Phone Number:

CCS Contact Email:

Is the individual currently receiving any services?

Multi choice*

Yes

No

If Yes, please provide details of current services or providers:

Preferred Contact Method:

Multi choice*

Phone

Email

Both

Best Time to Contact You:

Please specify days/times that are most convenient for a call

How did you hear about Ardmore?

Multi choice*

Website

Referral

Social Media

Other

Questions?

If you need assistance or have any questions,

please feel free to contact our Admissions team at:

(301) 306-2578

bmacklin@ardmoreenterprises.org

Thank you for choosing Ardmore!

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Since 1963...Empowering People with Intellectual and other Developmental Disabilities.

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4300 Forbes Boulevard, Suite 110

Lanham, MD 20706

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Ardmore Enterprises is a 501(c)3 nonprofit. EIN#: 52-0801367

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