Intake Application

Primary language if not English

Parent and/or Legal Guardian

(Required if applicant is a minor)

Qualifying Developmental Disability

Diagnoses Verification Sources

Current Physician

Previous Physician

Current or most recent school attended

Previous School Attended

Vocational Training Programs attended

Psychological/Psychiatric Services received

Other Services where Diagnostic Testing was Performed

Services Currently/Previously Received

Services Currently Sought From FCBDD

Informant Information