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First Resources Corp.

A Resource For The Community

Disability Services Application


Service Area

Desired Location

Services Requested

Check all that apply
Check all that apply
Check all that apply
Check all that apply

Keosauqua Location Only


Applicant Gender
Applicant Marital Status
Does the person have a legal guardian?
Does the person have a case manager or care coordinator?
Is the person on the Sexual Offender Registry?
Is the person under a mental health committal?
Is the person on probation?


Is the person being or recently been discharged from another provider?

Financial/Educational Information:

Does the person get SSI or SSDI?
Does this person get food stamps?
Does the person have a power of attorney?
Does the person have a burial plan or estate?
Does the person have a representative payee?
Does the person have a conservator?

Medical Information:

Is there a "Do Not Resuscitate" Order?
Is the person diabetic?
Is the person an Organ Donor?
Is there a history of seizures?
If yes, can they self-administer the insulin?
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Support Team Information:

Thank you for your interest in First Resources Corp!

Please call 641-682-8114 or email for any questions

In order to speed up the application process, please send or upload a copy of the following information:

Social History

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Current Individual Plan

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Copy of guardianship papers


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Additional Information

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Your application has been successfully submitted. Our referral team with be in contact with you soon!

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