Who Is Eligible?

An Individual must have a diagnosis of a mental disability, with an I.Q. of less than 70 to 75, depending on services requested. Third party sponsorship for funding or ability to pay for services must be established.

Fields marked with an * are required

Mission Statement: At Mid-Step Services, we are dedicated to providing residential, vocational,
educational and recreational services to people with intellectual disabilities in a caring,
supportive environment where each individual is encouraged to reach his or her highest


A. IDENTIFYING INFORMATION

Applicant:


If YES, complete:

List family members applicant has interaction with:



B. DISABILITY DESCRIPTION


C. MEDICAL

Physical description of applicant:


D. SENSORY/MOTOR SKILLS

Indicate whether or not applicant:


E. SOCIAL/BEHAVIORAL ADJUSTMENT/
DEVELOPMENT


F. COGNITIVE/COMMUNICATION

Indicate whether or not applicant can perform each of
the following skills/tasks/communication directives:


G. BEHAVIOR

Indicate the frequency of each behavior over the last 12 months where None means no incidents, Occasionally means less than once a month, Frequently means several times a week, and Daily once a day or more:

As best you can, indicate how independently applicant typically performs each activity: