Potential Client Inquiry Form|The Mustard Seed

POTENTIAL CLIENT INQUIRY FORM

We are a loving, Christian community for active adults with developmental disabilities.
We do not accept State or Federal funding (Medicaid/Medicare). Click here to see our Program Fee Scale
Families are responsible for ALL medical care.
Seedsters participate in a creative Ceramics Program and enjoy a range of recreational, social, and cultural activities supervised by staff both on and off campus.
To encourage family time for both Seedsters and staff, The Mustard Seed observes the following holidays: Good Friday through the following Monday, Memorial Day (including the weekend before and the Tuesday after), Thursday through Sunday at Thanksgiving, and two weeks at Christmas. During these times, there are no activities on campus, and our group homes are closed.

Your Name*
First Last
Email*
Daytime Phone*
Your relationship to the potential client*
Name of Potential Client*
Potential Client's Date of Birth*
MM slash DD slash YYYY
Potential Client's Physical Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Please tell us a little about the Potential Client (abilities, disabilities, interests, schooling, medical needs, etc.)*
Which program are you interested in for your loved one?*
- Day Program (M-F 8:30-4:30)
- Residential
Would the potential client require any type of assistance from the staff?*
- Yes
- No
- Maybe
Is YES or MAYBE, please explain*
Questions/Comments
A visit to The Mustard Seed's campus will be arranged for the family and potential client. This visit gives our staff a chance to meet the potential client and for the family to get a more in-depth view of the program. Once we receive your submission, we will followup with you and discuss your tour options.*
- I understand that this Potential Client Inquiry will expire after 2 years.
Unfortunately, we've had many issues with our emails sending to SPAM folders. So that we're able to respond to you in a timely manner, please understand that you may need to check your SPAM folder.*
- I understand that I may need to check my SPAM folder to find emails from The Mustard Seed.
Would you like to be added to our email list so that you can stay up to date on Mustard Seed events, special announcements, and Gift Shop specials?*
- Yes
- No

1085 Luckney Road
Brandon, MS 39047

PHONE 601-992-3556 (ext.1)

OFFICE HOURS
Monday-Friday 8:30am-4:30pm

GIFT SHOP HOURS
Monday-Friday 9am-4pm
Second Saturdays 10am-3pm

115 N. Wheatley Street
Ridgeland, MS 39157

PHONE 601-992-3556 (ext.2)

GIFT SHOP HOURS
Monday-Friday 9am-5pm
First Saturdays 10am-3pm