Susie Wingate's Site

We look forward to supporting you as your possible FMS provider. Please complete this intake form and we will reach out to you.

Participant's First Name

Participant's Last Name

Name of Regional Center

Regional Center Service Coordinator First Name

Regional Center Service Coordinator Last Name

Regional Center Service Coordinator Email

Participant's Address (Street)

Participant's Address (City)

Participant's Address (State)

Participant's Address (Zip Code)

Name of Main Point of Contact Supporting Client

Main Point of Contact Phone Number

Main Point of Contact Email

Participant's UCI # (this is found on their Regional Center IPP document)

Independent Facilitator (if applicable)

Independent Facilitator Email (if applicable)

Independent Facilitator Phone Number (if applicable)

Total Budget Amount (can be an estimate)

Anticipated Self Determination Program (SDP) Start Date

Are you transferring from another FMS? Y/N

If known, what model is your spending plan? (Bill Payer, Co-Employer and Sole Employer)

Bill Payer

Co-Employer

Sole Employer

Not Sure

If co-employer model, will any employee(s) work more then 29 hrs/week (more the 119 hrs/month)?

Yes

Not Using the Co-Employer Model