IDD Specialist Intake Form

IDD Specialist Intake Form
Type of Eligibility Needed:
NAME:
D.O.B.:
Is the Youth in an Out of Home Treatment Facility?
DD Eligibility Date:
CYBER ID (IF APPLICABLE):
Date of Referral:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referent:
Referent Email:
example@example.com
Referent Contact Number:
Care Manager (IF APPLICABLE):
Care Manager Sup. (IF APPLICABLE):
Parent/Guardian:
Parent/Guardian Contact Number:
Primary/Preferred Language
Address:
Presenting Reason for Referral:
Current Services through CMO
What services will the youth/family need through DDD?
Current Diagnosis:

Evaluations & Documentation & Guardianship
Name:
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
CYBER ID
Please Indicate Below the Evaluations that have been completed for the youth:

Other
Year of Psychological Evaluation
Year of ADOS/CARS/GARS/MCHAT Evaluation
Year of Neurodevelopmental Evaluation (MUST have assessment tool)
Year of 'Other' Evaluation
Is the Youth Medicaid Eligible?
Is the Youth's Birth Certificate Available/Accessible?
Is the Youth's Social Security Card Available/Accessible?
Is a NON-DRIVERS ID of Youth Available??
Does the Youth have a Medicaid/SSI Award Letter Available?
Guardianship Status?

Contact Information (please fill out all that are applicable to this referral)
Current Treating Physician:
Contact Number:
Current Treating Psychiatrist:
Contact Number:
School:
Contact Number:
School District:
Contact Number:
Out of District:
Contact Number:
CST Care Manager:
Contact Number:
DCPP Case Manager:
Contact Number:
DCPP Supervisor:
Contact Number:
Out of Home Name:
Out of Home Contact:
Contact Number:
Should be Empty: