All applications submitted to the Enrichment Center must be completed in full and all required documentation must be attached to receive consideration. Applications that have incomplete forms, missing information, or missing attachments, will not be forwarded to the Admissions committee for review and selection. Please note that all applicants must be at least 18 years of age. If you have questions or need assistance completing this application, please contact referrals@enrichmentarc.org

Individuals at the Enrichment Center participate in several activities both on and off site such as cookouts, holiday parties, trips to Hanging Rock, the Carolina Classic Fair. They also create art using a variety of media including canvas, linen, potter’s clay, colored glass, jeweler’s supplies, and more. The Enrichment Center seeks charitable gifts throughout the community to support these additional costs. To learn more about how to help, please visit our giving page: https://enrichmentarc.networkforgood.com/

Please fill in the chart below using the information exactly as it appears on the prescription. Use the generic name of the medication if that is what you are taking. If you are taking 50 mg of a medication, but you are actually taking two 25 mg tablets, write “25 mg” under “Dose” and the number “2” under “quantity”. If you take the same medication more than once a day, record the number of times per day under “Frequency”. Similarly, record the times you normally take your medication under “Time of Day” (for example: 10am / 8pm). If you are authorized to self-medicate, please indicate which medications you will be taking yourself by placing a check mark in the circle beside the name of that medication listed below. Click the + icon to add a new medication.

At the Enrichment Center, we believe that all behavior is a form of communication. Individuals often act out in a certain behavior when they are having difficulty communicating in a more traditional way. If we know which behaviors are more common for each participant, we can better understand that individual and explore creative ways to communicate more effectively. Please use this instrument to identify those behaviors that other people close to the applicant (including family) would associate with the applicant. There are no “right or wrong” behaviors. People deal with frustration differently – some become quiet and withdrawn while others become loud and aggressive, when both are experiencing the same difficulty. For each behavior identified, use the scale on the right to measure how often the behavior is observed. If the individual has NEVER demonstrated a behavior, select “0” instead of leaving an item blank.

Please indicate your transportation arrangements for getting to and from the Enrichment Center.

Please document your work history up to and including your fourth employer (if applicable). You may include school-based work experience and any volunteer work that was performed on a regularly scheduled basis for a time period of at least three months. Begin with your current or last employer and record in reverse chronological order (from last to first).

Please answer each of the questions to the best of your ability. If you would like assistance or need clarification for any of the questions, you may contact referrals@enrichmentarc.org

The following scale will help us determine the level of care you will need so we can deliver individualized services. These represent the tasks that a person must develop in order to live independently. We would like to help you live as independently as you want. This will be our starting place. Please rate each one based on the scale below.

By signing this document you are giving The Enrichment Center permission to disclose personal identifying information in order to coordinate care with your regional LME/MCO and to ensure that your name is enrolled on that organization’s waiting list for services. This includes Protected Health Information (PHI), which encompasses Individually Identifiable Health Information (IIHI) as defined by the Federal Health Insurance Portability and Accountability Act (HIPAA).