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Next STEP Initial Application

Contact Information

Student's Name

Preferred Nickname if Applicable

Gender

Male

Female

Date of Birth

Phone #

Address

City/Town

State

ZIP

Guardian Status

Self

Parent

Other

If other selected, please type below

Emergency Contacts

Mother/Guardian's Name

Mother/Guardian's Address (if different from applicant)

Address

City/Town

State

ZIP

Mother/Guardian's Home Phone

Mother/Guardian's Employer

Mother/Guardian's Work Phone

Mother/Guardian's Cell Phone

Mother/Guardian's Email

Father/Guardian's Name

Father/Guardian's Address (if different from applicant)

Address

City/Town

State

ZIP

Father/Guardian's Home Phone

Father/Guardian's Employer

Father/Guardian's Work Phone

Father/Guardian's Cell Phone

Father/Guardian's Email

Please select the program you would like to attend

Full time: (Monday-Friday: 9am-5pm) $244 per week

Part time: (3 days a week 9am-5pm) $163 per week

Early Drop off: 8 - 9am for $10.30 per day

Payments may be made at the beginning of each week or eachmonth. PSL Services/STRIVE accepts personal checks, as well as MasterCard, Visa, and Discover.

Please check off the days and times you would like to attend:

Monday

9:00am-5:00pm

9:00am-1:00pm

1:00pm-5:00pm

Tuesday

9:00am-5:00pm

9:00am-1:00pm

1:00pm-5:00pm

Wednesday

9:00am-5:00pm

9:00am-1:00pm

1:00pm-5:00pm

Thursday

9:00am-5:00pm

9:00am-1:00pm

1:00pm-5:00pm

Friday

9:00am-5:00pm

9:00am-1:00pm

1:00pm-5:00pm

Does student have a case manager?

Yes

If yes, please fill out the following information about this case manager: Name, Organization, Email, Phone #

Name

Organization

Phone #

Student Information

Please complete the following section as thoroughly as possible. This information will enable us to plan a safe and successful experience for the students. Please check all that apply.

ADD

ADHD

Asthma

Aparaxia

Arthritis

Asperger's

Autism

Bi Polar

Blind

Brain Injury

Cerebral Palsy

Deaf

Diabetes

Dual Diagnosis

Down Syndrome

Intellectual Disability

OCD

Paraplegic

PDD

Quadriplegic

Scoliosis

Seizure Disorder

Spina Bifida

OTHER

If "other" is selected, please provide information here

Uses wheelchair

Yes

Uses walker

Yes

Wears braces

Yes

Has allergies

Yes

Uses crutches

Yes

Has seizures

Yes

Takes medication

Yes

Wears contact lenses

Yes

Incontinence

Yes

Has special diet

Yes

Loose stool

Yes

Has catheter

Yes

Wears helmet

Yes

Has shunt

Yes

Chair repositioning

Yes

Comments:

Please describe

Communication: How does the student communicate? Please note any special signs or gestures if applicable.

Does the student have behavioral outbursts?

Yes

If so, please explain

Does the student have a history of fighting with peers?

Yes

If so, please explain

Does the student exhibit aggressive/confrontational behavior (i.e. bullying, antagonizing, name calling etc.)?

Yes

If so, please explain

Socialization

What are the student’s strengths, abilities, and talents?

What kind of social outlets, if any, does the student have?

Please describe any difficulties that a student may have. Please be as specific as possible.

Educational

Does the student like to work independently or in groups?

Yes

What academic classes is the student interested in?

How does the student feel about attending Next STEP?

Leave this field blank

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Upcoming Events

PSL Services/STRIVE closed - Happy Holidays!
December 24, 2021, 12:00 am - December 24, 2021, 11:59 pm

See more upcoming events

News

Successful night for STRIVE Rocks 2021 fundraiser

6 months 3 weeks ago

STRIVE Rocks raises $104k to support mission

6 months 3 weeks 1 day ago

A sneak peek at the hard work it takes to make STRIVE Rocks happen

6 months 3 weeks 1 day ago

See more news articles

PSL Services/STRIVE Central Office
39 Darling Ave
South Portland, ME 04106
Phone: 207-879-0847
Fax: 207-879-1516

PSL Services/STRIVE Center
28 Foden Road
South Portland, ME 04106
Phone: 207-774-6278
Fax: 207-774-7695

Email us: info@pslstrive.org

Contact Form

Request Information

OUR MISSION

PSL Services/STRIVE provides people with intellectual and developmental disabilities or mental health diagnoses a community of support and assistance in finding greater independence by:

Respecting the value of each individual
Initiating mutually beneficial, sustainable partnerships with business and community leaders
Creating innovative opportunities responsive to the evolving needs of individuals and families

Our Values

We will treat everyone with dignity and respect
We are committed to understanding the unique abilities of our participants, employees and partners
We will STRIVE to create a fun and professional environment while recognizing the magnitude of what we do

NEWSLETTER

Current issue: November 2021

Employee Satisfaction Survey 2019 results available here

SUPPORT PSL SERVICES/STRIVE

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