Division of Developmental Disabilities Intake Questionnaire

This simple intake questionnaire will help us prepare for our first meeting. Please answer the following questions as carefully as possible.

Date of Consultation

Provide Date

Please provide your contact information.

Full Legal Name(Required)

First Last

Birth Date(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Cell Phone Number(Required)

Home Phone Number(Required)

Business Phone Number(Required)

Email(Required)

Enter Email Confirm Email

Relationship to child(Required)

Please provide the following information about your child.

Full Legal Name(Required)

Birth Date(Required)

Current Age of Child(Required)

Child is currently taking short-term or long-term medications.(Required)

Names and Purposes of Medications(Required)

About Your Child's Environment

Briefly describe the current living situation of child.(Required)

Briefly describe any problems your child encounters at home, if applicable.(Required)

Briefly describe any problems your child encounters at school, if applicable.(Required)

Briefly describe any problems your child encounters in your community, if applicable.(Required)

Answer the following yes or no questions regarding your child.

Do you have Guardianship over your child?(Required)

Have you applied for Medicaid for your child?(Required)

Does your child receive Supplemental Security Income?(Required)

Do you have a Special Needs Trust?(Required)

Have you applied to DDD in the past?(Required)

Provide information regarding your child's diagnoses and treating professionals.

Provide information about your child's diagnoses.(Required)

Provide names and contact information for the treating professionals who are most familiar with your child's disabilities.

Hidden

Professional 1

Name of Professional(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Business Phone Number(Required)

Email(Required)

Relationship to Child(Required)

Add a second professional?

Yes

Hidden

Professional 2

Name of Professional

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Business Phone Number

Relationship to Child

Add a third professional?

Yes

Hidden

Professional 3

Name of Professional

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Business Phone Number

Relationship to Child

Add a fourth professional?

Yes

Hidden

Professional 4

Name of Professional

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Business Phone Number

Relationship to Child

Hidden

Support Coordinators

Please provide contact information for your child's Disabled Individuals Support coordinator(s).

Hidden

Support Coordinator 1

Name of Professional(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Business Phone Number(Required)

Email(Required)

Add a second professional?

Yes

Hidden

Support Coordinator 2

Name of Professional

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Business Phone Number

Hidden

Referral

Who referred you?

We'd love to know — how were you referred to us?(Required)

ex.: a friend's recommendation, our website, etc.

Hidden

Enter Email

End of Special/General Education Questionnaire

Enter your email to complete this form.(Required)

Thank you for completing the Special/General Education Questionnaire. If you don't receive confirmation in your email, please check your junk mail.

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This simple intake questionnaire will help us prepare for our first meeting. Please answer the following questions as carefully as possible.

Date of Consultation

Please provide your contact information.

Please provide the following information about your child.

About Your Child's Environment

Answer the following yes or no questions regarding your child.

Provide information regarding your child's diagnoses and treating professionals.

Professional 1

Professional 2

Professional 3

Professional 4

Support Coordinators

Please provide contact information for your child's Disabled Individuals Support coordinator(s).

Support Coordinator 1

Support Coordinator 2

Referral

Who referred you?

Enter Email

End of Special/General Education Questionnaire

Contact us now

For a Private Consultation

SPECIAL NEEDS

Estate Planning

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