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(602) 993-5153

info@dec-az.com

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Prospective Client Intake

Please Fill In All Required Fields *
Client's First Name*
Client's Last Name*
Gender*
Email*
Phone*
Date of Birth*
Month
Day
Year
Home Address*
Street Address Address Line 2 City State ZIP Code
Diagnosis*
- Alzheimers
- Autism
- Cerebral Palsy
- Cognitive Delay
- Dementia Related Disorders
- Epilepsy
- MMR
- Other (enter below)
Other Diagnosis
Special Medical Concerns
- Feeding
- Hearing
- Speech
- Vision
- Wheelchair
Services Requested*
- Adult Day Treatment & Training (DTA)
- Senior Day Treatment & Training (DTA)
- Summer Program for Children & Youth (DTS)
- After School Program (DTT)
- Adult Developmental Homes
- Group Supported Employment (GSE)
- In Home Care for Developmental Disabilities
- Training Classes
- Family Support
Anticipated Start Date*
MM slash DD slash YYYY
Support Coordinator
Additional Comments or Questions
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Schedule a Tour

If you are interested in seeing how our day to day operations work and if DEC is right for your family member, please click the link below and allow us to give you a tour of our facility!

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Our Location

16809 North 53rd Ave.,
Suite 1, 2 and 3
Glendale, Arizona 85306

Administration

Phone:
(602) 993-5153
Fax:
(602) 993-5163

Phone Numbers

Phone:
(602) 314-4214
Fax:
(602) 314-4564

After Hours:
(602) 390-0887
Home Care After Hours:
(602) 390-0887
Programs After Hours:
(602) 679-3084

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