Intake Application

FCBDD ➤ Intake Application

Intake Application

Applicant's First Name(Required)

Applicant's Middle Name(Required)

Applicant's Last Name(Required)

Previous Name (Maiden name, pre-adoption or legal change)

Applicant's Date of Birth(Required)

Gender(Required)

Male

Female

Other

Gender Identification

Preferred Pronouns

Preferred Communication Method

Postal Mail

Email (including electronic signatures for releases of information)

Phone

Address(Required)

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

Primary Phone(Required)

Secondary Phone

Email(Required)

Primary language if not English

Will you require interpreter services?(Required)

Yes

Name (of person completing this form)

Informant Name(Required)

First Last

Relationship to applicant*

Phone(Required)

Email(Required)

Parent and/or Legal Guardian

(Required if applicant is a minor)

Relationship (select from drop down)(Required)

Name(Required)

First Last

Address(Required)

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

Phone(Required)

Email(Required)

Qualifying Developmental Disability

Primary developmental disability diagnosis (prior to the age of 22)(Required)

Diagnosed By

At Age

Would you like to add another developmental disability diagnosis?

Additional Development Disability

Diagnosed by

At age

Current medical or psychiatric diagnoses

Current medications (if None, enter "None" in box)

Diagnoses Verification Sources Current Physician

Name(Required)

First Last

Specialty(Required)

Name of Clinic or Practice

Address

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

Would you like to add another current Physician?(Required)

Yes

Physician 2 Name

First Last

Specialty Physician 2

Name of Clinic Physician 2

Physician 2 Address

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

Previous Physician Name

First Last

Previous Physician Specialty

Previous Physician Clinic Name

Previous Physician Address

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

Would you like to add another previous Physician?

Yes

Previous Physician 2 Name

First Last

Previous Physician 2 Specialty

Previous Physician 2 Clinic Name

Previous Physician 2 Address

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

Current or most recent school attended

School Name(Required)

District(Required)

Previous School Attended

School Name

District

Would you like to add another previous school attended?

Yes

School Name

District

Vocational Training Programs attended

Name

Address

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

Psychological/Psychiatric Services received

Name

First Last

Specialty

Name of Clinic or Practice

Address

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

Would you like to add another Psychological/Psychiatric Services received?

Yes

Name

First Last

Specialty

Name of Clinic or Practice

Address

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

Other Locations where Diagnostic Testing was Performed

Name

Address

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

Services Currently/Previously Received

County Board of Developmental Disabilities

Social Security Benefits

Children’s Services

Services Currently Sought From FCBDD

Describe what services or assistance you are seeking for the applicant(Required)

Other information you would like FCBDD to know

If you have electronic records that will help with the eligibility process, please feel free to upload them with this form. Examples of helpful documents include school records (all ETRs and current IEP), medical records related to the individual’s developmental disability, and any evaluations that have been completed (psychological evaluations, diagnostic assessments, etc.). We will also need to obtain a copy of the applicant’s birth certificate, social security card, and insurance card. If you have electronic copies of any of these documents, please upload them with this form.

File

Drop files here or

Max. file size: 16 MB.

Franklin County Board of Developmental Disabilities

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