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    • Apply for Services
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Application for Services at Systems Unlimited

Complete a referral application by filling in the fields below. Note: Applicants must be on the ID waiver, BI waiver, or have habilitation or region funding to be considered for services. To learn more about our application process, please visit our Services page.

Applicant Information

Name(Required)
Gender(Required)
Address(Required)

Funding

Check all that apply
Check all that apply
Check on Managed Care Organization (MCO)
Address

Services Requested

Check All that Apply
Day Program Services - Level of Supervision Needed (if applicable)
(If Applicable)
(If Applicable)

Service and Support Needs

Service Area (check all that apply)(Required)
Potential Roomates(Required)
Guardian (check one)(Required)
Guardian Relationship
Guardian Name
Address
Accessible Housing Needs
Check all that apply

Assessment of Skills/Needs

Communication (check all that apply)
Behavioral Support Needs(Required)
Check Behavioral Supports Needed
Physical Aggression
Mental Health
Self-Injurious
Sexually Inappropriate
Verbal Aggression
Property Destruction
Self Stimulation
Elopement/Wandering
Medical Support Needs(Required)
Check Skilled Medical Supports Needed
Feeding Tube
Ostomy
Insulin Support
Catheter
Seizures

Activities of Daily Living

Feeding
Dressing
Hygiene
Toileting

Instrumental ADL's

Medications
Meal Prep
Cleaning
Transportation
Shopping
Finances

Additional Support Needs

Criminal Record(Required)
Active Substance Abuse(Required)
History of Aggression in Vehicles(Required)
(MCO Plan, Social History, SIS Assessment, Behavioral Plans)
Drop files here or
Max. file size: 512 MB.
    Systems Unlimited logo

    A non-profit leader for more than 50 years in Eastern Iowa.

    Delivering high-quality, personalized, and individualized social services support for people with disabilities and mental health needs.

    Contact Us

    • Phone: 800.401.3665
    • Email: info@sui.org
    • Fax: 319.341.9443
    • Referrals: referrals@sui.org
    • Main Office:
      2533 Scott Blvd
      Iowa City, IA 52240

    • View All Locations

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