Date of Consultation You need to select an item to continue
Answer the following yes or no questions regarding your child.
Do you have Guardianship over your child? Yes No
Have you applied for Medicaid for your child? Yes No
Does your child receive Supplemental Security Income? Yes No
Do you have a Special Needs Trust? Yes No
Have you applied to DDD in the past? Yes No
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Please provide your contact information. You need to select an item to continue
Who referred you? You need to select an item to continue
Please provide the following information about your child. Names and Purposes of Medications
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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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About Your Child's Environment You need to select an item to continue
Please provide your contact information. You need to select an item to continue
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.
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Please provide contact information for your child's Disabled Individuals Support coodinator(s). You need to select an item to continue
End of Division of Developmental Disabilities Intake Questionnaire
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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