Charles Lea Center : Services : 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