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Am I Eligible
- Eligibility
Services
Resources
About Us
Contact Us
For Providers

Intake Referral/Application Ages 3-5

Intake Referral/Application Form – Ages 3-5

Intake Referral Application form for Summit DD services for individuals ages 3-5 years old.

Step 1 of 8

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APPLICANT INFORMATION

Please use this section for APPLICANT information.

Name of Child(Required)

First Middle Last

Date of Birth(Required)

Month

Day

Year

Please upload your child's birth certificate to complete your application

Accepted file types: jpg, pdf, Max. file size: 512 MB.

Social Security Number*

(*required by the end of the eligibility process)

Do you currently receive Medicaid?(Required)

Yes

Medicaid #(Required)

Child Lives with(Required)

Choose one of the following

Residential Address(Required)

Street Address line 1 Address line 2 City State ZIP Code

Parent/Guardian Email(Required)

Enter Email Confirm Email

Parent/Guardian Phone(Required)

DEMOGRAPHICS

Applicant Demographic Information

Gender(Required)

Ethnicity

Race

Primary Language

Secondary Language

Interpreter Needed(Required)

Yes

Cultural Considerations

Please share any important cultural information or considerations

SCHOOL INFORMATION

Please share schooling information about individual applying for services

School District

Student is on

IEP

ETR

504 Plan

Special Education Classes

Choose all that apply

Please upload your child's Individual Education Program (IEP) to continue

Drop files here or

Accepted file types: jpg, pdf, Max. file size: 512 MB.

What resources are you currently utilizing?

Therapy

Medical home

Preschool

Other

If selecting Other, please list

What support do you need from Summit DD right now?

OTHER SUPPORTING AGENCIES

List any additional agencies currently receiving support from

Additional Agencies

Summit County Children Services

FCFC (Family & Children First Council)

OhioRise

Other

If selecting Other, please list

DIAGNOSIS INFORMATION

Information regarding diagnosis of a developmental disability

Has the child received Early Intervention services before?

Yes

Developmental Disability Diagnosis

Original Diagnosing Doctor (or Agency)

Diagnosing Doctor or Agency Address

City State / Province / Region

Diagnosing Doctor or Agency Phone Number

List Doctors, Hospitals, or Specialists that may have records of diagnosis and/or treatment

Please include any additional information that might be helpful here

PARENT OR GUARDIAN INFORMATION

*Provide legal documentation for Guardian or Power of Attorney

Parent/ Guardian Name

First Last

Parent/Guardian Phone

Parent/Guardian Email

Parent/Guardian Address

Street Address Address Line 2 City State ZIP Code

Relationship

Mother

Father

Legal Guardian*

Power of Attorney*

Upload Legal Documentation

Max. file size: 512 MB.

REFERRAL SOURCE (If different from parent/guardian)

If referral is being filled out by the individual, parent or guardian, please skip this section)

Referral Name (if different from parent/guardian)

First Last

Organization Name

Relationship to the Individual

Referral Source Phone Number (if different from parent/guardian)

Referral Source Email (if different from parent/guardian)

Enter Email Confirm Email

Referral Source Address

Street Address Address Line 2 City State ZIP Code

CONSENT TO APPLY FOR SUMMIT DD SERVICES

Please have the applicant/guardian sign and date below if they are consenting to applying for Summit DD Services and initiating our Eligibility Process. Applicant may also assign a representative to help them with the process, but it is not required.

Eligibility Process Consent(Required)

I give my consent to start the eligibility process with the Summit County Board of Developmental Disabilities Intake Department.

Signature(Required)

Parent signature

Guardian/POA signature

Signature

Please type name

Guardian/POA signature

Please type name

2355 2nd Street, Cuyahoga Falls, OH 44221

Contact Us

pr@summitdd.org
330-634-8000

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Phone

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