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  • 2026 Equipment Request Form

    Cuyahoga DD Family Supports Program

  • (To be completed by an OT, OTA, PT, PTA, SLP, or Licensed Physician)

    If you have questions before completing this request, please reach out to the Family Supports Coordinators at 216-736-2947

  • Individual/Family Information

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  • Equipment Requested:

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    • The following release must be signed by the parent/guardian before NEON is able to process the request for equipment

      Cuyahoga DD - Release of Liability Waiver for Family Support Services: Installation and/or Assembly of Sensory Equipment

      I acknowledge that I am responsible for the installation and/or assembly of the equipment requested from Cuyahoga County Board of DD.

      I hereby agree to indemnify and hold harmless the Cuyahoga County Board of Developmental Disabilities and its employees or agents from and against any and all claims, suits, damages, or causes of action resulting in whole or part, directly or indirectly, from my installation and/or assembly of Cuyahoga DD Family Supports Funded Equipment at my residence, and against any orders or decrees or judgments which may be entered therein, brought for damages or alleged damages, resulting from any injury to person and/or property or loss of life sustained by any person or persons whatever.

    • Clear
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    • Additional clinical documentation may be requested

    • ****Family Authorization****

    • I reviewed the recommended equipment with the family who agreed to use their Family Supports Program funds to purchase the requested item(s):

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    • Equipment to be delivered to:

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    • Questions? Call the Cuyahoga DD Family Supports Coordinators at 216-736-2947
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