Please answer all questions, then click 'Submit' below to complete:

What services are you applying for (check all that apply): *

Adult Group Home: Long-term group homes for adults with intellectual/developmental disabilities, mental illness, or both. Staffed 24/7 by caring direct support professionals.

Adult Intermediate Care Facility (ICF) Home: The highest level of care Monarch provides in a group home setting for adults with intellectual/developmental disabilities. Includes increased staffing ratios and additional assistance with activities of daily living. Staffed 24/7 by caring direct support professionals.

Child Intermediate Care Facility (ICF) Home: for children ages 0-18 with intellectual/developmental disabilities. Includes increased staffing ratios and additional assistance with activities of daily living. Staffed 24/7 by caring direct support professionals.

Supervised Apartment (Adult): The lowest level of residential care Monarch provides for people with intellectual/developmental disabilities, mental illness, or both who do not require 24-hour staff support but do need minimal guidance to ensure successful independent living.

Adult Alternative Family Living (AFL): In an AFL setting, people with intellectual and developmental disabilities reside within the home of a host family who has been trained to provide them with services and support. Requires the NC Innovations Waiver or B3/State Funded Innovations Services.

Community Services (Provided in personal home/location): For people with intellectual/developmental disabilities, mental illness, or both. Service availability is dependent on managed care organization (MCO) funding availability, location, diagnostic criteria, and other factors that will be determined through Monarch’s screening process. These services do not include Enhanced Mental Health Services such as ACTT, CST, or Peer Support. If you’re seeking an enhanced mental health service, please contact referrals@monarchnc.org.

Adult I/DD Day Program: For adults with intellectual and developmental disabilities. These programs provide support to adults in need of gaining skills used in the community or the workplace.

Counties in which services are being sought *

Name of Person Completing This Form: *

Relation to Applicant *

Agency/Organization

Email Address: *

Contact Number: *

Applicant's Information

Applicant’s First Name *

Applicant’s Last Name *

Applicant’s Street Address *

Applicant’s Address Line 2

Applicant’s City *

Applicant’s State *

Applicant’s County *

Applicant’s Zip Code *

Applicant’s Phone Number *

Applicant’s Email Address *

Applicant’s Gender: *

Male

Female

Applicant’s Date of Birth: * +

Applicant’s Race *

Is the applicant linked with a Managed Care Organization? *

Yes

No

Select the Care Management Agency

Applicant’s current health insurance (Select all that apply) *

NC Innovations Waiver

Please choose the Applicant’s current Medicaid plan:

NC Medicaid Direct

AmeriHealth Caritas North Carolina, Inc.

Blue Cross and Blue Shield of North Carolina

UnitedHealthcare of North Carolina, Inc.

Carolina Complete Health

WellCare of North Carolina Inc.

Unsure

Please Specify Private Insurance:

Does the Applicant have a Legally Appointed Guardian? *

Yes

No

Guardian First Name

Guardian Last Name

Guardian Street Address

Guardian Address Line 2

Guardian City

Guardian State

Guardian Zip Code

Guardian Phone Number

Guardian Email Address

Does Applicant have a Primary Care Physician? *

Yes

No

Has Applicant had a physical exam in the past 12 months?

Yes

No

Name of Provider/Practice:

Provider/Practice Phone Number:

Provider/Practice Fax Number:

Is Applicant currently experiencing any of the following health problems? (Check all that apply)

Diabetes