Residential Application

Residential Services Application

Step 1 of 5

This application takes 1-2 hours to complete. Please be sure that you have all of your documentation at the time of starting the application and complete in one sitting.
IS UMAR A FIT FOR ME?
UMAR serves adults with a PRIMARY DIAGNOSIS of intellectual and developmental disabilities (IDD).
In order to qualify to receive our services, the applicant's IQ cannot exceed 70.
If you meet both of the above criteria, we encourage you to apply for our residential, day, and/or vocational services.
After submitting the application, you will be required to upload the following materials within 48 hours:
- Recent psychological report
- Applicant photograph
- Medical history
- Behavioral evaluations/modification plans (if applicable)
- Current service plan (if applicable)
If you have any technical issues, please contact marketing@umarnc.org.
Person submitting application*
First Last Relationship to Applicant
Resident Information
Name*
First Middle Last Preferred Name
Gender*
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Phone*
Type of Placement*
Which area are you applying for?*
Which area are you applying for?*
If you selected 'Other', please explain
What has caused you to seek residential placement at this time?*
Please identify services that are needed for the applicant to stay in his/her residential placement.*
Family Contact Information
Parent Name*
First Middle Last
Parent Email*
Parent Home/Cell Phone*
Parent Work Phone
Parent Address (If different from above)
Street Address Address Line 2 City State ZIP Code
Emergency Contact*
First Last
Emergency Contact Address*
Street Address Address Line 2 City State ZIP Code
Emergency Contact Email
Emergency Contact Home Phone*
Emergency Contact Work Phone
Referral Data
Case Manager/Other Individual
Agency Name (if applicable)
Program or Contact Address*
Street Address Address Line 2 City State ZIP Code
Relationship to Applicant*
If you selected 'Other', please explain
Legal Guardianship Status
Legal Guardian Name
First Middle Last
Type of Guardianship (If Applicable)
County of Adjudication
Date of Adjudication
MM slash DD slash YYYY
Legal Guardian Address
Street Address Address Line 2 City State ZIP Code
Legal Guardian Email
Legal Guardian Home Phone
Legal Guardian Work Phone

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Financial Information
Income (SSI, Social Security, Employment, Etc.)*
Source of Income Monthly Amount
Does applicant have an Innovations Waiver*
Is applicant his/her own payee?*
If you selected 'No', please explain*
Property - Please list description and location
Real Estate Real Estate Value Other Property Other Property Value
Savings Accounts, Stocks, Checking Accounts
Account Value
Insurance Information
Is applicant a Medicaid recipient, or eligible recipient?*
Medicaid Number*
Is applicant a Medicare recipient, or eligible recipient?*
Medicare Number*
Does the applicant have private insurance?*
Private Insurance Information
Company Name Company Address City State ZIP Code
Policy/Group Holder Name Subscriber ID/Group Number Number of Policies

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Certification
UMAR prohibits the use of illegal drugs or other criminal activities. Do you engage in illegal drug use or other criminal activity?*
- Yes
- No
By checking the boxes below, I certify that all pertinent information regarding behavioral problems, sexual problems, psychological problems, drug use, criminal activity, and any incidents that have occurred in these areas have been given to the admissions committee. No information has been withheld. I hereby give my consent for release of all medical information and social, vocational, and psychological evaluations as needed to the UMAR Admissions Committee for the purpose of determining eligibility for placement in UMAR Services, Inc. I also understand that a drug and criminal check may be performed prior to admission.*
- Applicant Agrees
- Witness (Parent or Guardian) Agrees
Applicant Statement
I hereby apply for admission to the UMAR Residential Program. I agree to abide by the rules and regulations of the home and understand that violation of the rules can result in discharge.*
- Applicant Agrees
- Witness (Parent or Guardian) Agrees
Required File Uploads
The following materials are required within 48 hours of submitting your application:

- Recent psychological report
- Applicant photograph
- Medical history
- Behavioral evaluations/modification plans (if applicable)
- Current service plan (if applicable)

If you have any trouble uploading the files, please mail copies to the following address:

UMAR Services, Inc.
Attn: Admissions
5350 77 Center Drive, Suite 201
Charlotte, NC 28217
Email to: umaradmissions@umarnc.org
File Upload
Drop files here or

Accepted file types: jpg, pdf, Max. file size: 1 MB.

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Medication Name	Dosage and Frequency	Route	Purpose of Medication	Compliance Issues

	Not an Issue	Mild	Moderate	Severe
Cries/Screams Excessively
Excessive Anger
Excessive Lying
History of Running Away
Inappropriate Sexual Behavior
Physically Assaultive
PICA/Attempts to Eat Inedibles
Property Damage
Self Injurious
Self Stimulation
Steals
Verbally Assaultive

Residential Services Application

Step 1 of 5

Resident Information

Family Contact Information

Referral Data

Legal Guardianship Status

Diagnoses - DSM V

Axis I - Primary Diagnosis

Axis II - Personality Disorder

Axis III - General Medical Conditions

Axis IV - Psychosocial and Environmental

Axis V - Global Assessment of Functioning (GAF Score)

Physical Health Care

Mental Health

Vision, Hearing, and Dental

Current Applicant Services

Independent Living Abilities

Social History

Financial Information

Insurance Information

Certification

Applicant Statement

Required File Uploads

ABOUT US

RESIDENTIAL

DAY PROGRAMS

VOCATIONAL

QUICK LINKS

5350 77 CENTER DR. SUITE 201 CHARLOTTE, NC 28217 | 704.875.1328

Real Estate	Real Estate Value	Other Property	Other Property Value

Date	Reason	Location

Date	Type	Notes

Where	When

Where	When

Residential Services Application

Step 1 of 5

Resident Information

Family Contact Information

Referral Data

Legal Guardianship Status

Diagnoses - DSM V

Axis I - Primary Diagnosis

Axis II - Personality Disorder

Axis III - General Medical Conditions

Axis IV - Psychosocial and Environmental

Axis V - Global Assessment of Functioning (GAF Score)

Physical Health Care

Mental Health

Vision, Hearing, and Dental

Current Applicant Services

Independent Living Abilities

Social History

Financial Information

Insurance Information

Certification

Applicant Statement

Required File Uploads

ABOUT US

RESIDENTIAL

DAY PROGRAMS

VOCATIONAL

QUICK LINKS

5350 77 CENTER DR. SUITE 201 CHARLOTTE, NC 28217 | 704.875.1328​

5350 77 CENTER DR. SUITE 201 CHARLOTTE, NC 28217 | 704.875.1328