Intake Application

18+(Required)

I certify that I am the individual over the age of 18 seeking supports, the parent of an individual under the age of 18 who is seeking supports, or the legal guardian of an individual seeking supports

For individuals ages 3 and above seeking services, please contact the Franklin County Developmental Disabilities Intake Department at (614) 342-5490 (Monday through Friday 8am to 4:30pm) for a prescreening or complete the secure web based online prescreening form below. Before completing the form, please note that the person seeking supports must confirm that:

the disability is attributable to physical or mental impairments other than a sole diagnosis of mental illness;
the person’s disability(s) was manifested before the age of 22;
the person’s disability is likely to continue indefinitely.
the individual and/or court appointed legal guardian is a resident of Franklin County, OH.

If the answer is yes to all statements above, please complete the form and a representative from the Intake Department will review it and contact the individual, family or legal guardian as applicable for additional information.

Applicant's First Name(Required)

Applicant's Middle Name

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

Primary Phone(Required)

Secondary Phone

Email(Required)

Will you require interpreter services?(Required)

Yes

Select Preferred Language

Please Clarify

Parent and/or Legal Guardian

(Required if applicant is a minor)

Is this individual under the age of 18 or is there a court appointed legal guardian?(Required)

Yes

Relationship (select from drop down)(Required)

Name(Required)

First Last

Address(Required)

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

Phone(Required)

Email(Required)

Qualifying Developmental Disability

Developmental disability diagnosis (prior to the age of 22)(Required)

Diagnosed By

At Age

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

County Board of DD Services Currently/ Previously Received

Services

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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