Life Centers of Kansas is currently on a waiting list basis for residential services. However, Life Centers is pleased to announce an upcoming expansion in early 2012 to best serve each individual waiting for services.

Please fill out the information below to complete the waiting list request.

We Look forward to working with each individual and their support team to build a long lasting relationship!

Life Centers of Kansas

Internal Waiting List Request

Date of request:

Services Requested: (Select all that apply)  

Day Supports  

Residential Supports 

Name of individual requesting services:

DOB:

Male

Female

Is this individual eligible and/or receiving HCBS funding?

Yes

No

Current Diagnosis:

Current Tier Level: (select one) 1      2     3     4     5

24 Hour Supports Required? Yes No

Daily Supports Needed:

Name of Case Manager:

Case Manager Phone:

Guardian Name:

Guardian Phone:

Contact Email:

Desired start date:

Desired living arrangement:

Does this individual need any adaptive equipment or ADA accessibility? If so, please specify.

Any Special requests or information: