Apply 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

First Name

Last Name

Date of Birth

Medicaid ID

Primary Contact Name

Primary Contact Phone

Gender

Male Female Other

Address

City

State

Zip

Applicant Phone

Services Requested

Check All that Apply

24 Hour - Supported Community Living (Adult) 24 Hour - Supported Community Living (Child-RBSCL) 24 Hour - Supported Community Living (Adult), plus SUI Day Program or Supported Employment ONLY Day Program Services ONLY Supported Employment Services Elderly

Hourly Supported Community Living (Adult):
(If Applicable)

Hourly Supported Community Living (Child):
(If Applicable)

CDAC:
(If Applicable)

Elderly Services

CDAC:
(If Applicable)

Respite:
(If Applicable)

Funding

Check one

Has funding in place On a waiting list Applying for funding None

Check all that apply

HCBS/Waiver Intellectual Disability, Tier Level MFP Brain Injury

Check one Managed Care Organization (MCO)

Amerigroup Iowa Total Care Molina HIPP

CM/Care Coordinator

Email Address

Agency

Address

City

State

Zip

Service and Support Needs

Primary Disability

Other Diagnosis

Potential Roommates

Male Only Female Only Any Gender can be considered

Guardian (check one)

Yes No

Guardian Relationship

Mother Father Both Parents Other

Guardian Information

Name

Phone

Address

City

State

Zip

Accessible Housing Needs

Yes No

Assessment of Skills/Needs

Communication (check all that apply)

Verbal Gestures Vocalizations Non-verbal

Type of support needed

Behavioral Support Needs

Yes No

Medical Support Needs

Yes No

Skilled Cares (i.e. feeding tube, ostomy, insulin, catheter, etc) Seizures

Activities of Daily Living

Feeding

Independent Support Needed

Dressing

Independent Support Needed

Hygiene

Independent Support Needed

Toileting

Independent Support Needed

Instrumental ADL's

Medications

Independent Support Needed

Meal Prep

Independent Support Needed

Cleaning

Independent Support Needed

Transportation

Independent Support Needed

Shopping

Independent Support Needed

Finances

Independent Support Needed

Please attach the following documents if you have them:
(MCO Plan, Social History, SIS Assessment, Behavioral Plans)

Upload all that apply. Mulitple files allowed.

Any other pertinent information

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.

Apply for Services at Systems Unlimited

Applicant Information

Services Requested

Funding

Service and Support Needs

Assessment of Skills/Needs

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