(DTA) Adult Program – Choices Day Treatment Centers

Our Adult Program is geared to consumers 18 years old and older and provides specialized sensory-motor, cognitive, communicative, social interaction and behavioral training. We have cultivated this service for the consumer to increase or maintain his/her self-help, socialization, and adaptive skills to reside independently and participate successfully in the community.

DTA Adult Program Registration Form

Consumer Information
Please list all the persons you are requesting services for, along with ages and diagnosis.*
Name Age Diagnosis
Do any of the listed consumers have a second diagnosis?
If there is a secondary for any of the above consumer's please list them here:*
Name Diagnosis
Requestor Information
Requestor's Name*
First Last
Requestor’s Email*
Requestor’s Phone*
Support Coordinator*
First Last
Support Coordinator's Phone*
Desired Consumer Start Date*
MM slash DD slash YYYY
When is the best time to call?

: Hours

Minutes

AM/PM
Do you need transportation?
- Yes
- No
Comments
This field is for validation purposes and should be left unchanged.

Name	Age	Diagnosis

Name	Diagnosis

DTA Adult Program Registration Form

Consumer Information

Requestor Information