"*" indicates required fields Next Steps InquiryPlease complete this short questionnaire to help Rainbow Acres gain a general idea about the special needs person interested in living at Rainbow Acres. The full application, if requested, will require more detailed information. (Information provided will always remain confidential). At any time, you may save this form and return later to finish.Person Completing ApplicationName of Person Completing Application* First Last Relationship to Potential Resident*Guardian Name* First Last Phone*Email* Preferred Method of Contact*PhoneEmailHow did you hear about Rainbow Acres?*Prospective ResidentProspective Resident's Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Age*Gender*MaleFemalePrimary Diagnosis*Secondary Diagnosis*Major Medical Conditions*Current Psychological Evaluation* Yes No Date* MM slash DD slash YYYY Interacts well with others* Yes No Usually Has worked in the general community* Yes No Cooperates with/Consideration of others* Yes No Usually Main Things That Cause Anxiety*History of Harm to Self or Others* Yes No If yes, please explain*Independent Personal Care & Grooming* Yes No Yes, with assistance Appropriate Behavior When in Public* Yes No Appropriate Behavior with The Opposite Sex* Yes No Usually Able to Read (Check all that apply)* Read Write Tell Time Handle Money None Select AllNeed for Supervision* Constant Moderate Can be Left Alone for Short Periods Listens To and Follows Directions* Yes No Self-Regulates Temper* Yes No Usually Respects Property of Others* Yes No Has the Applicant Ever Lived in a Special Needs Community Before?* Yes No What is Your Biggest Hope for the Applicant’s Future?*Upload FilesYou may upload any relevant files for the potential resident.Files Drop files here or Select files Accepted file types: jpeg, png, pdf, Max. file size: 512 MB. Rainbow Acres CriteriaPlease review our criteria for Admission to Rainbow Acres location on our website.Have you reviewed the criteria on the Rainbow Acres website?* Yes No Have you reviewed our current cost of care?* Yes No Rainbow Acres is a private pay option. Social Security funds can be used toward the fees. New scholarship arrangements are not currently available. Thank YouThank you for your interest in Rainbow Acres. When this application has been reviewed, the Director of Admissions will contact you by phone or email to answer any questions you may have.EmailThis field is for validation purposes and should be left unchanged. Δ
