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Providence Family Life Center
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Disability Prescreen
First name
Last name
Email
Birthday
Phone
You may be eligible if you meet 3 or more criteria (check all that apply):
Have at least 6 to 12 months of consistent care by a physician or specialist
Difficulty in concentrating and remembering things
Past hospitalization against the person’s will and/or current mental health treatment(at least 12 mos of recent treatment history)
Self-report of multiple physical health conditions or observations of serious health conditions
Tri-morbidity (co-occurring mental and substance use disorder with a chronic medical condition)
Unable to manage hygiene or living skills
Experiencing homelessness or at risk for homelessness
History of serious brain injury or head trauma
Unable to work due to the conditions selected above
Child with IEP or 504 plan
Tell us about your work history
Check here if you have applied and have been denied in the past
Check here if you are working with an attorney
Submit
Complete the prescreen questionnaire and a member of the team will follow-up with you to discuss next steps.
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