Self Determination Menu About Application Self Determination Initiative Application Thank You! Your form submission has been successfully sent. Downloadable Application Form Application - Word Format Application - PDF Application Name and Contact Information First Name Last Name Address City State Zip Phone Number Date of Birth Resource Coordinator Eligibility Questions I live in Jefferson County and I am 18 years old or older. Yes No I have been determined eligible for Developmental Disability Services. Yes No I have completed a Futures Planning Meeting or Planning Alternative Tomorrows with Hope (PATH) plan. Yes No If you answered YES to all the questions above, continue with the application. If you answerd NO to a question above, please contact Katie Talierio at 303-462-6528. General Questions Are you currently enrolled in services through DDRC or any other CCB? If yes, what are these services? Describe your goal(s). What private pay or no-cost resources have you identified to support your goals? (These may be identified in your future planning process) Plan Supports and Cost What Supports do you need to work toward your goals? Please use the following fields NameCost/UnitTotal Cost Long Term Success Self-Determination is designed to help you be more involved in your community, become more independent and feel that you have authority over your own life. We know many of your goals will take months, sometimes years, and the Self-Determination Initiative provides a jump start for working to achieve your goals. Please tell us how you plan to use this jump start support to achieve long-term success? Thank you for taking the time to tell us about your plans for the future. Please submit your completed application to a DDRC Resource Coordinator or Self-Advocacy Coordinator. You will receive a letter, typically with in 45 days, explaining what will and will not be paid for and the reason why. Funding for this project is approved on an individual basis. The Self-Determination Allocation Committee will review and approve applications based on funds available. All funds must be spent by June 30th 2018.