Self Determination Initiative Application

Application for the DDRC Self-Determination Initiative

Self-Determination is a Jefferson County mill-levy funded program, which encourages you to identify your personal plans and goals and provides short-term financial support to jumpstart your dreams.

If you’re unsure how Self-Determination can help, have questions about your application, or just want to brainstorm what resources are available to you, you can call or email the Community Funding Coordinator, Julia Panucza, at (303)-462-6528 / julia.panucza@ddrcco.com

Applications are reviewed by the Self-Determination Committee on the second Wednesday of the month. Please submit your application by the first Wednesday of the month to ensure your request is reviewed that month.

Name

Email Address

Date of Birth

Address

How do you prefer that we communicate with you?

Guardian’s information (if applicable)


Is there anyone else (a family member, friend, provider) you would like to be involved in planning or in your application process?


I live in Jefferson County and I am 18 years old or older.

I have been determined eligible for Developmental Disability Services.

ABOUT YOU

1. Please describe your goal(s). How do you plan to use Self-Determination support to achieve long-term success? 2. Have you talked with your team (family, friends, Resource Coordinator, others) about your goals? What other available resources have you identified? 3. What items or supports are you requesting to reach your goals? Please note specifics if you have a program or provider in mind.

Costs

Name and desribe the supports you need (service or item) (Please include details about duration, cost per hour, etc) How much will the total cost be? (Please sum the total cost of the above items and services) Total Cost

4. Have you applied and/or been approved for Self-Determination before? 5. Self-Determination is set up to provide short-term financial support as you’re working toward a goal. We ask that after a request is approved, you identify other resources available for any ongoing, long-term support. What plans do you have to sustain progress toward your goals when Self-Determination funding concludes?