Apply for placement

Applicant’s Name (*)

Name of Person Completing Application(*)

Phone Number (*)

Relationship to Applicant (*)



Is the applicant his/her own guardian? (*)

 Yes  No

If no, please list the name and phone number of the guardian.

Name (*)

Phone Number (*)

Applicant Personal Information

Gender(*)

Applicant’s Current Residence

City(*)

State(*)

Phone Number(*)

Does applicant have Medicaid? (*)

 Yes  No

If so, what type? (*)

 Traditional, no waiver  Traditional, with waiver  Arkansas Medicaid expansion-BCBS

Was diagnosis of the applicant’s intellectual or developmental disability made by a licensed physician prior to the age of 21? (*)

 Yes  No

Does the applicant have a Certificate of Completion or High School Diploma? (*)

 Yes  No

If no, is applicant currently in high school? (*)

 Yes  No

If yes, what school?(*)

When will he/she graduate? (*)

Has the applicant had a psychological examination completed within the past five years? (*)

 Yes  No

Can you provide a copy upon request? (*)

 Yes  No

Does the applicant take any medication that he/she cannot swallow or inject on his/her own? (*)

 Yes  No

Services Requested (*)

Is the applicant currently receiving services through another provider?(*)

 Yes  No

If so, what organization is providing those services? (*)

A representative from Arkansas Center for Independence will contact you the next business day.

How would you prefer to be contacted? (*)

 Telephone  E-mail

Email address (*)

What is the best time to contact you?(*)

How did you find out about us?(*)

 Social Media  Website  Newspaper  Radio  State Agency  Other

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More Old Treasures Thrift Store

March 25, 2015
More Old Treasures is a thrift store locally owned and operated by the non-profit organization, Arkansas Center for Independence (ACI). The store is located at 1019 Malcolm Avenue in Newport, across from O’Reilly’s Auto Parts. More Old Treasures is stocked with assortments of name brand clothing, shoes, accessories, jewelry, books, home décor, furniture and so much more. All merchandise in the store has been generously donated by the community. All sales go to support ACI in order to assist the non-profit organization in achieving its goals of providing services and employment to adults with developmental disabilities.