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(602) 597-0285

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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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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

Main Program & Admin
16809 N. 53rd Ave., Ste 1-3
Glendale, Arizona 85306

Phone Numbers

Contact Us:
(602) 597-0285

All services and after hours needs are now available by calling our main number.

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