Apply To Join Sunbreak Society As A Client

Please fill out the questionnaire below and we will reach out within 2 business days.

Client First Name

Client Last Name

Client Date of Birth

Client Address

Client Height

Client Weight

Client Gender

Hours per Month in ISP or SA

Name of current DSP/PSW/Caregiver

Phone # of current DSP/PSW/Caregiver

Current DSP/PSW/Caregiver working days/hours per week

Email of current DSP/PSW/Caregiver

Parent/Guardian Name(s)

Parent/Guardian Email(s)

Parent/Guardian Relationship to Client

Parent/Guardian Phone #(s)

Name of Case Manager:

Email of Case Manager:

Is there a need for medication administration?

Yes

Is there any nursing care involved? (Such as G-tube, Insulin.. etc)

Yes

Description, if nursing care is involved

Is there an up-to-date/current behavior plan?

Yes

Who is current client Behavior Professional (if there is one)

Are there any special protocols in place? (Such as seizures, diabetes.. etc)

Yes

Description, if special protocols are in place

Message

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Upload Support Plan/File

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8835 SW Canyon Ln #404a, Portland, OR 97225

503-862-3061

Mon - Fri:

8:00 am – 5:00 pm

Weekend:

Call or Email