To apply for Easterseals services, use the Easterseals program application form from your local affiliate — there is no single national form. Start at easterseals.com/find-your-easterseals, locate the office that covers your area, and request or download that affiliate’s intake paperwork. From there, the path is predictable: complete the form, provide the supporting information it asks for, and sit down with an intake coordinator for a phone or in-person meeting.
Start By Finding Your Local Affiliate
Easterseals runs as a network of local affiliates, each covering a defined region and choosing which programs to offer based on community need and funding. The form you need, the submission method, the timelines, and even which services exist all depend on where you live.
On the “Find an Easterseals near you” page, you can search by ZIP code with a radius of 50, 100, or 200 miles, or browse by state. The results point to your local affiliate’s own website, where you can get the application, find a phone number, and see the list of programs that office actually runs. If more than one affiliate shows up, pick the one whose service area covers your home address and call to confirm if you aren’t sure.
Programs commonly offered across the network include early childhood intervention and autism evaluations, day habilitation for adults with disabilities, supported employment and job coaching, supported community living, veteran services, senior services and adult day care, and respite care for family caregivers. Veteran services are open to any veteran regardless of age or disability status; a service-connected condition is not required. Not every affiliate runs every program, so check the local list before you fill anything out.
What the Application Asks For
Each affiliate designs its own form, but the categories tend to be the same. The Easterseals Iowa application is a reasonable guide to what to expect.
Personal and Contact Information
Plan to provide the applicant’s full legal name, date of birth, home address, phone, email, gender, ethnicity, marital status, and primary language. Some forms ask for a Medicaid or state ID number, and the Iowa form asks about military or veteran status. You’ll list an emergency contact with name, phone, and relationship.
If the applicant has a legal guardian, their name, address, phone, and email go in a separate section. A case manager’s contact information and agency name have their own field. Supported employment referrals may include a dedicated line for the applicant’s vocational rehabilitation counselor.
Diagnosis and Reason for Referral
The form asks for a primary diagnosis, a secondary diagnosis, and a short explanation of why you’re applying. You don’t need to attach a full medical history at this stage. Some affiliates, including the Birmingham office, keep the medical section minimal and ask only for “pertinent medical or possible risks information” such as seizure disorders or severe allergies that staff should know about.
Activities of Daily Living
This is the most detailed part of most applications. You’ll rate the applicant’s independence across a checklist that includes personal hygiene, bathing, dressing, oral care, toileting, eating, meal preparation, housekeeping, laundry, walking, reading and writing, making purchases, and wheelchair mobility. For each task, note whether the person is independent, needs some help, or needs full assistance. If adaptive equipment is in use — a Hoyer lift, hospital bed, shower bench, wheelchair — list those too.
Behavioral and Communication Needs
Many forms include a behavioral section covering things like verbal or physical aggression, elopement risk, difficulty with transitions, and overstimulation. A separate communication section asks whether the applicant uses a communication device, sign language, braille, or large-print materials, or is non-verbal or visually impaired. Specific answers here help the intake team plan staffing and accommodations.
Funding Source
You’ll identify how services will be paid for: Medicaid, Medicare, private insurance, vocational rehabilitation funding, or self-pay. Some forms also ask you to check off current benefits like SSI, SSDI, food assistance, or public housing. This section lets the affiliate set up billing and flag whether financial assistance may be available.
Tips Before You Sit Down With the Form
Pull together a few things first: the applicant’s insurance or Medicaid card, contact details for their doctors and case manager, and any recent evaluation reports that name specific diagnoses. You usually don’t need to send stacks of records with the initial application; the intake coordinator will ask for more documentation if they need it.
When you describe daily living needs, be thorough rather than optimistic. If someone needs verbal prompts to brush their teeth, that is “needs assistance,” not “independent.” The intake team sizes the level of support from these answers, and understating needs leads to a poor program match.
Write clearly on paper forms and check that every required field has an answer. Missing information is the most common reason applications stall before reaching the intake stage. When a field doesn’t apply, write “N/A” so staff can tell you didn’t skip it by mistake.
How to Submit the Application
Submission routes depend on the affiliate. Some offices take forms through a secure online portal or by email, some prefer fax or mail, and many accept walk-ins. The affiliate’s website or front desk can tell you which method they use. Easterseals Rio Grande Valley, for example, accepts referrals by phone, email, fax, or mail.
If the office asks for supporting documents up front, such as an insurance card copy or a recent evaluation, send copies rather than originals. For mail, use a tracked service so you have proof of delivery.
What Happens After You Submit
Sending the form in is the start of the intake process, not the end of it. An intake coordinator reviews the application and may ask for additional records: a medical examination, a current social history and assessment, vocational testing, educational evaluations, or reports from other agencies.
The coordinator then schedules an intake meeting, sometimes called an intake staffing. It brings together the applicant, the guardian if there is one, the referring party, and the funding source. Staff explain program expectations, go over the applicant’s goals, and estimate how long services may be needed. Some programs add an in-person functional assessment at this stage. Autism evaluations may combine behavioral observation, developmental testing, parent interviews, and eye-tracking technology. Senior services referrals may include an in-home assessment by a registered nurse and social worker to confirm medical eligibility.
At Easterseals Iowa, the admission decision comes within 14 business days after the intake meeting. Other affiliates set their own timelines, so ask yours what to expect. If the applicant is approved, both the applicant and the referring agency get a letter confirming placement on the approved list, and enrollment happens as space opens up.
Waitlists
Many programs run at capacity, so approval doesn’t always mean immediate enrollment. Some affiliates follow Medicaid Provider Manual guidelines for ordering their waitlist, while others use first-come, first-served. Ask your office how their list works and whether factors like medical urgency can move someone up. Stay in touch while you wait. If the applicant’s condition changes significantly, tell the coordinator — a real change in support needs can affect both program fit and position on the list.
If You’re Turned Down
When an applicant doesn’t meet a program’s admission criteria, or the referred program isn’t a good match, the affiliate sends a written notice with the reason. Where possible, the letter includes a referral to another agency or program.
If you think the decision was wrong, affiliates maintain formal grievance processes. The specifics vary, but the general structure is: submit a written grievance to the affiliate’s client rights specialist, who investigates and issues a written report with findings and recommendations, typically within 30 days. If you disagree, you can escalate to the affiliate’s president for a written decision, and from there request an administrative review. The full policy should be in your local affiliate’s intake packet or on its website.
Paying for Services
What you pay depends on the program, your coverage, and your household income. Many services are covered partially or fully by Medicaid, Medicare, or private insurance. Some affiliates bill insurance as a courtesy even when they’re out-of-network, but call your insurer to verify benefits before services start.
If you’re uninsured, underinsured, or facing high out-of-pocket costs, most affiliates offer financial assistance. Easterseals uses sliding fee scales based on family size and income, and some locations have donated or restricted funds set aside for families who qualify. You’ll usually complete a separate fee reduction application and provide income documentation. Call the affiliate’s billing department to ask what’s available before you assume cost is a barrier.