Waiver-Based Services Inquiry

If you are interested in Quest services, please fill out the form below.

To inquire about Medicaid Waiver-based services including Adult Day Training, Group Homes, Adult Behavior Therapy and Transitional Living, please complete the inquiry form below.

En Español

Step 1 of 2

Are you currently qualified for Medicaid Waiver-based services with the Agency for Persons with Disabilities (APD)?(Required)

Yes

No

To begin the process of seeking Medicaid Home and Community Based Waiver Services, please reach out to the Agency for Persons with Disabilities (APD):

APD - Applying for Services

More helpful information on APD and the Waiver application process can be found here:

APD & Waiver Process

Primary Contact Info

Name(Required)

First Last

Email(Required)

Phone(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred Method of Communication

Phone

Email

Client Info

Name

First Last

Age

Diagnosis

Program of Interest(Required)

Other Program of Interest(Required)

Are you interested in assessment or ongoing services?(Required)

Yes

No

Unsure

Where are services needed?

Home/Home and Community

What type of funding does the client have?

Name of your support coordinator

First Last

Support Coordinator Phone Number

Support Coordinator Email

Does the client have any behaviors to note?

Waiver-Based Services Inquiry

Primary Contact Info

Client Info

Contact

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Programs

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