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.

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

Name of Professional

Address Line 1

Address Line 2

City

State

Zip Code

Business Phone Number

Add a second professional

Name of Professional

Address 1

Address 2

City

State

Zip Code

Business Phone Number

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

Provide information about your child's diagnoses.

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

Name of Professional

Address Line 1

Address Line 2

City

State

Zip Code

Business Phone Number

Relationship to Child

Add a second professional

Name of Professional

Address 1

Address 2

City

State

Zip Code

Business Phone Number

Relationship to Child

Add a third professional

Name of Professional

Address 1

Address 2

City

State

Zip Code

Business Phone Number

Relationship to Child

Add a fourth professional

Name of Professional

Address 1

Address 2

City

State

Zip Code

Business Phone Number

Relationship to Child

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About Your Child's Environment

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About Your Child's Environment

Briefly describe the current living situation of child.

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

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

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

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Who referred you?

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

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

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Please provide the following information about your child.

Full Legal Name

Birth Date

Current Age of Child

Child is currently taking short-term or long-term medications.

Names and Purposes of Medications

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Please provide your contact information.

Full Legal Name

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone Number

Home Phone Number

Business Phone Number

Relationship to child

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Answer the following yes or no questions regarding your child.

Do you have Guardianship over your child?

Have you applied for Medicaid for your child?

Does your child receive Supplemental Security Income?

Do you have a Special Needs Trust?

Have you applied to DDD in the past?

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Date of Consultation

Provide Date

Date Unknown

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End of Division of Developmental Disabilities Intake Questionnaire

Enter your email to complete this form.

Thank you for completing the Division of Developmental Disabilities Intake Questionnaire. Our office will contact you with any further questions. If you don't receive confirmation in your email, please check your junk mail.

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