Family Support Application 2025-2026

Family Support Services Application

Thank you for applying for funds through the Georgia State Funded Family Support Program. Please note that State Funded Family Support funds are intended to be used as a last resort and you should utilize other programs before applying for this program. Please print clearly and fill out all pages, including your signature at the end of the application.

Any application not completed in full will not be considered.

ATTENTION: New applications should be submitted by April 1st, 2026.

Section I: Demographic Information
Section I: Demographic Information
Date of Application*

MonthDayYear
Date
Individual Name:*

First NameLast Name
Social Security Number*
Gender

FemaleMale
Date of Birth:*

MonthDayYear
Date
Age*
Race (optional)

American Indian or Alaskan NativeAsian or Pacific IslanderAfrican AmericanCaucasian/ AngeloMulti-Racial Ethnic GroupOther
Ethnicity (optional)

Non-HispanicHispanic or Latino
Insurance Carrier (Private)
Insurance (Public Medicaid) Number
Family Member/ Guardian Name*

First NameLast Name
Relationship to the Individual:*

Legal Guardian of the Adult IndividualParent of a minor childOther
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence*

FultonDekalbCobbDouglassNewtonGwinnettRockdale
Notification of Denial of Application.

Good day Applicant

We thank you for applying for Family Support Funding with InCommunity. However, we are unable to provide funding resources to you because of the county that you reside in. We are only contracted to accept applications from families that are in the counties above.

We appreciate you considering InCommunity for your funding needs. The State of Georgia has several member agencies that are located in your area. Please reach out to the Department of Behavioral Health and Developmental Disabilities for a listing of the Agencies that can assist you in obtaing the Family Support Funding.

Thank you again and we wish you the best in obtaining the funding for your family.

Family Support Team
Phone*
Email*
example@example.com
Section II: Diagnostic Information
Check the supporting documentation attached to this application:

Please attach a copy of the most recent psychological evaluation,Individual Education Plan (IEP), and/or any other evaluations/documentation with diagnostic information.Failure to provide supporting documentation will result in the application not being considered.
Check which of the following disability categories is most relevant to the identified individual:
Section II: Diagnostic Information Developmental Disability Diagnosis:*
Age at Time of Diagnosis
Supporting Documentation:
Most Current Psychological Evaluation ONLY(File Upload)*

Cancelof
Most Current IEP ONLY (File Upload)

Cancelof
Additional Documents (As needed)

Cancelof
Check the supporting documentation attached to this*

DBHDD I&E Assessment School IEPSocial Security Disability Determination (SS)Medical VerificationSchool IEPPsychlogical EvaluationOther
Section III: Current Service Information
Please check all current services that the applicant is receiving.*

Family Support or on a waiting list of another AgencyNew Options Waiver (NOW)Comprehensive Supports Waiver (COMPDBHDD State Funded ServicesCurrently on DBHDD Planning ListType option 5Deeming Waiver (katy Beckett)Vocation RehabilitationFood StampsIndividual Education Plan (IEP)ARDC Options-CounselingChild Care AssistanceAdoption AssistanceSocial Security Disability (SSI)SOURCEGAAPOther
Section IV: Services Needs/Request
From the list below, please check the services/goods your family has identified as needing: (After your application has been approved, an assessment will be conducted to determine which services/goods will be awarded based on need and available funding
Please check all that apply*

Respite CareCommunity Living SupportCommunity AccessDental ServicesMedical CareVision CareSpecialized ClothingSpecialized Diagnostic ServicesEnvironmental ServicesSpecialized Equipment / Assistive TechnologyTherapeutic ServicesCounseling ServicesParent /Family, TrainingExceptional Disability Related Living CostsTransportation ReinbursementVehicle Adaptation ServicesChild Day Care / Day Care & After School ServicesOther Family Support ServicesRecreation / Social Community Integration ActivitiesFinancial and Life Planning AssistanceBehavioral Consultation and SupportSupported EmploymentSpecialized NutritionSuppliesIncontient Supplies
Please check ALL sources of the Individuals current natural support network
Please select all that apply

FamilyFriendsChurchSocial GroupsCoworkersSupport GroupOther
Are you receiving Family Support or Respite currently through another Agency?*

YesNo
Are the services/goods identified above accessible through other sources?

YesNo
Have the services/goods identified above been denied through other sources?

YesNo
Describe the benefit to the family if the services and goods above were funded:*
Section V: Agreement Section
I understand to be eligible for the Family Support Program the individual/applicant must be diagnosed with adevelopmental disability prior to the age of 22 and live in a family member's home. I hereby confirm that theinformation given at the time of application is true and accurate to the best of my knowledge
Individuals Signature (If over 18 years of age)

Clear
Date

MonthDayYear
Date
Individuals Printed Name:

First NameLast Name
Date

MonthDayYear
Date
Parents/legal Guardian's Signature(If under the age of 18)

First NameLast Name
Parent/Guardian's Printed Name

Clear
INDIVIDUAL FAMILY SUPPORT PLAN (IFSP)
Date of Plan Start: July 1, 2025 Date of Plan End: June 30, 2026
Description of Applicant:*
Who are they? Their likes, dislikes, and personality.
What is Important to you:*
What are the expectations of the family and how the funding will help their quality of life.
What is important for you: *
What is most important to the applicant and how will this funding help them achieve their goals this year.
Describe the family dynamics:*
Current Support Network

Please choose all that apply.
Current Services Information: Current Services Received: List all current services/resources utilized by the applicant and family below:*

New Options Waiver (NOW)Currently on DBHDD Planning ListICWPCCSPDeeming Waiver (Katie Beckett)Vocational RehabilitationFood StampsIndividual Educational Plan (IEP)TADRC-Options CounselingComprehensive Waiver (COMP)SOURCEGAPPDBHDD State Funded ServicesChild Care Assistance (CAPAdoption AssistanceSocial Security Disability (SSDI)
Services Needs/Request Please check the services/goods your family has identified as needing*

RespiteCommunity AccessSpecialized Medical Supplies & Specialized ClothingRecreational/Social Integration ActivitiesAfter School CareMedical/Dental/Vision careSpecialized Medical Supplies & Specialized ClothingNutritionBehavioral Support and ConsultationTherapeutic Services/Environmental ModificationTransportation/Vehicle Adaptation ServicesOther
DISCLAIMER:(Please read in it's entirety)

Georgia Community Support & Solutions dba Incommunity,has the right to withdraw awarded Family Support funds if they are not utilized within the first 90 days of the signed Family Support Plan. I/We attest that we were informed of our right to participate in the development of this Individualized Family Support Plan, and were given the ability to identity services and goods based on my/our family priority of needs for services/goods. I/We understand that Family Support Services is a non- entitlement program and InCommunity dba Georgia Community Support and Solutions cannot fund all the service and goods that I/We may request, and that funding levels can and might change from each funding year and are subject to funding limitations. I/We agree with the Individual Family Support Plan, Family Support Agreement, and the disclaimers above:
Your Answer to the above disclaimer:*

YesNo
Section V: Agreement Section:

I understand to be eligible for the Family Support Program the individual/applicant must be diagnosed with a developmental disability prior to the age of 22 and live in a family member's home. I hereby confirm that the information given at the time of application is true and accurate to the best of my knowledge.
Individuals Signature or Mark If over 18 years of age.

Clear
Date

MonthDayYear
Individual's Name Printed *

First NameLast Name
Parent/Legal Guardians Signature If under the age of 18

Clear
Date

MonthDayYear
Date
Printed Parent/Guardians Name*

First NameLast Name
Individualized Family Support Services Application

For Agency/Provider Office Use Only

Section VI: Eligibility Review and Determination
Individuals Name

First NameLast Name
Date Completed Application Received

MonthDayYear
Date
Disposition for Family Support:

( ) Eligible For Family Support Services (Forward Application and Supporting Documents to the Regional RSA

( ) Ineligible For Family Support Services
Provider Agency Name
Provider Staff Name

First NameLast Name
Title
Phone Number:
Please enter a valid phone number.
Email Address:
example@example.com
Provider Staff Signature:

Clear
Date:

MonthDayYear
Date
Section VI: For Regional Office Use Only
Date Application Received

MonthDayYear
Date
Date Application Reviewed

MonthDayYear
Date
Disposition for Family Support:

( ) Yes Eligible Status Verified:

( ) No - State the reason (s):
Provider
Date of Notification

MonthDayYear
Date
Regional Staff's Name

First NameLast Name
Title
Regional Staffs Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Section I: Demographic Information

Section II: Diagnostic Information

Supporting Documentation:

Section III: Current Service Information

Section IV: Services Needs/Request

Section V: Agreement Section

INDIVIDUAL FAMILY SUPPORT PLAN (IFSP)

Date of Plan Start: July 1, 2025 Date of Plan End: June 30, 2026

Current Support Network