Charles Lea Center : Services & Support : Apply for Services : Application Form

Individual for whom services are requested:

Age of Individual:

Individual's county and state of residence:

Does this individual currently receive services from the SC Department of Disabilities and Speical Needs (DDSN)?:

If yes, which Disabilities and Special Needs (DSN) Board or provider does he/she receive services from?:

Your Name:

Address:

City, State, ZIP:

Phone Number:

Fax Number:

Email Address:

Service(s) Requested:

Additional Information:

Preferred Response: