Service Inquiry Form(For New Clients only. If you are a current client, please contact your mentor or coach for information on additional services) Client Name * First Name Last Name Client Phone Number * (###) ### #### Client Email * City you live in: * County: * Name of person completing form Relationship to client Parent/Guardian Name First Name Last Name Relationship to Client Parent/Guardian Phone Number (###) ### #### Parent/Guardian Email How did you hear about Harrigan Development Services? * Google Search HDS Website Facebook LinkedIn Instagram Referral from Friend Referral from Funding Source (please specify below) Other (please specify below) If you selected “Referral from Funding Source” or “Other” above, please tell us who to thank for the referral! Current Funding Sources, (if any): Division of Vocational Rehabilitation (DVR) CPS IRIS Children’s Long-Term Support Waiver (CLTS) CCS Juvenile Justice Family Care Private Pay Why are you interested in working with HDS? Please summarize your concerns, behaviors, goals, etc. * If you are interested in Mentoring Services, what goals do you hope to work on? For a more in-depth explanation of our Mentoring Services, please refer to the Professional Mentoring Services page of our website. Social Skills Development Independent Living Skills Emotional Regulation and Coping Skills Parent/Sibling Education and Support Developing Appropriate Behaviors Increasing self-confidence Cooking Skills Other (please specify below) If you selected “Other” above, please describe the specific services you are interested in: What vocational services are you interested in receiving? For a more in-depth explanation of our Vocational Services, please refer to the Vocational Services page of our website. Job-Related Skills Exploring Job Options Finding a job Basic Computer Skills Training Other (please specify below) If you selected “Other” above, please describe the specific services you are interested in: Group Services: Please see our Group Services page for days/times of our current group offerings! OT Social Skills: Social Skills Development, Independent Living Skills, Emotional Regulation and Coping Skills, Increasing self-confidence Cooking Skills Parent/Sibling Education & Support Compass: Activity-based opportunities for peer social interaction and community engagement What type of services do you prefer? 1-on-1 Group Combination of Both What days and times of the week are you typically available to receive services? * Do you have any specific questions for us? Thank you for your interest in working with us! A member of our team will be in touch with you soon!
