Getting Started Form

Please enter your information here

First name of person filling out form

Last name of person filling out form

Email of person filling out form

Phone number of person filling out form

Who are you seeking services for?

Please answer the remaining questions on this form on behalf of the person seeking services.

Person Seeking Services

What kind of service/support are you seeking?

YAI is currently offering services in New York, New Jersey, and California. Please check out our FAQ below to learn where to look for resources in other states.

What is the person seeking service's state of residence?

What is the person seeking service's county of residence?

Other County:

OPWDD eligible?

Have Medicaid ?

Medicaid ID number

If you have Medicaid, the Medicaid ID number starts with 2 letters, then 5 numbers, and ends with 1 letter. i.e. XX00000X

Does the person have a diagnosed intellectual or developmental disability? (For example: autism spectrum disorder, intellectual disability, cerebral palsy, Down syndrome)*

YesNoUnsure

Does the person have eligibility with the Office for People With Developmental Disabilities (OPWDD)?

YesNoUnsure

Most of YAI’s services support people with an intellectual or developmental disability (I/DD). If you do not have an I/DD diagnosis, you may be better supported by another organization.

Age of person seeking services?

Any further information or questions?

Hidden Fields

GSF - Programs of Interest

GSF - Person has ID/DD

GSF - Birthdate

GSF - Service Type Requested

CFS Form Submissions Name

CFS Form Type

Contact Type