2026 Cuyahoga DD Family Supports Equipment Request Form

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
Acknowledgment:*

I understand that the following items cannot be purchased utilizing Family Supports Funding: Toys and items typical for an individual's developmental age ▪ Outdoor swing sets ▪ Books and puzzles ▪ Medical equipment ▪ Trampolines, pools, spas, saunas ▪ Items solely for entertainment or recreation ▪ Gaming consoles and laptops ▪ General utility items (furniture, toothbrush, etc.) ▪ Devices used only to restrict movement or function ▪

Individual/Family Information
Individual FIRST Name:*
Individual LAST Name:*
D.O.B*

MonthDayYear
Date
Weight of Individual
Height of Individual (feet/inches)
Date of assessment*

MonthDayYear
Date
Diagnosis*
Parent/Guardian Full Name (Enter N/A if not applicable)*
Family Email Address*
example@example.com
Family Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Family Address*

Street Address (Apt.#/Suite#)

Street Address Line 2

CityState

Zip Code
Equipment Requested:
How many items/equipment need purchased?*

Please upload pictures of all item(s) being requested (include quotes if applicable):

Cancelof
ITEM #1 INFORMATION:
Item #1 Rationale
What is the purpose of this equipment and how will the Individual benefit therapeutically?*
Has the person been assessed with this type of equipment previous to this request?*

YesNo
How do you know it will work?*
Who will set up and train the family or individual on the new equipment (if applicable)?
I have verified that there is sufficient space in the individual's home for the requested equipment:*

YesN/A
- ITEM #2 INFORMATION:
- Item #2 Rationale
- Is the rationale for this item the same as Item #1?*
  
  YesNo
- What is the purpose of this equipment and how will the Individual benefit therapeutically?*
- Has the person been assessed with this type of equipment previous to this request?*
  
  YesNo
- How do you know it will work?*
- Who will set up and train the family or individual on the new equipment (if applicable)?
- I have verified that there is sufficient space in the individual's home for the requested equipment:*
  
  YesN/A
- ITEM #3 INFORMATION:
- Item #3 Rationale
- Is the rationale for this item the same as any of the other items above?*
  
  YesNo
- What is the purpose of this equipment and how will the Individual benefit therapeutically?*
- Has the person been assessed with this type of equipment previous to this request?*
  
  YesNo
- How do you know it will work?*
- Who will set up and train the family or individual on the new equipment (if applicable)?
- I have verified that there is sufficient space in the individual's home for the requested equipment:*
  
  YesN/A
- ITEM #4 INFORMATION:
- Item #4 Rationale
- Is the rationale for this item the same as any of the other items above?*
  
  YesNo
- What is the purpose of this equipment and how will the Individual benefit therapeutically?*
- Has the person been assessed with this type of equipment previous to this request?*
  
  YesNo
- How do you know it will work?*
- Who will set up and train the family or individual on the new equipment (if applicable)?
- I have verified that there is sufficient space in the individual's home for the requested equipment:*
  
  YesN/A
- ITEM #5 INFORMATION:
- Item #5 Rationale
- Is the rationale for this item the same as any of the other items above?*
  
  YesNo
- What is the purpose of this equipment and how will the Individual benefit therapeutically?*
- Has the person been assessed with this type of equipment previous to this request?*
  
  YesNo
- How do you know it will work?*
- Who will set up and train the family or individual on the new equipment (if applicable)?
- I have verified that there is sufficient space in the individual's home for the requested equipment:*
  
  YesN/A
- ITEM #6 INFORMATION:
- Item #6 Rationale
- Is the rationale for this item the same as any of the other items above?*
  
  YesNo
- What is the purpose of this equipment and how will the Individual benefit therapeutically?*
- Has the person been assessed with this type of equipment previous to this request?*
  
  YesNo
- How do you know it will work?*
- Who will set up and train the family or individual on the new equipment (if applicable)?
- I have verified that there is sufficient space in the individual's home for the requested equipment:*
  
  YesN/A
- ITEM #7 INFORMATION:
- Item #7 Rationale
- Is the rationale for this item the same as any of the other items above?*
  
  YesNo
- What is the purpose of this equipment and how will the Individual benefit therapeutically?*
- Has the person been assessed with this type of equipment previous to this request?*
  
  YesNo
- How do you know it will work?*
- Who will set up and train the family or individual on the new equipment (if applicable)?
- I have verified that there is sufficient space in the individual's home for the requested equipment:*
  
  YesN/A
- ITEM #8 INFORMATION:
- Item #8 Rationale
- Is the rationale for this item the same as any of the other items above?*
  
  YesNo
- What is the purpose of this equipment and how will the Individual benefit therapeutically?*
- Has the person been assessed with this type of equipment previous to this request?*
  
  YesNo
- How do you know it will work?*
- Who will set up and train the family or individual on the new equipment (if applicable)?
- I have verified that there is sufficient space in the individual's home for the requested equipment:*
  
  YesN/A
- ITEM #9 INFORMATION:
- Item #9 Rationale
- Is the rationale for this item the same as any of the other items above?*
  
  YesNo
- What is the purpose of this equipment and how will the Individual benefit therapeutically?*
- Has the person been assessed with this type of equipment previous to this request?*
  
  YesNo
- How do you know it will work?*
- Who will set up and train the family or individual on the new equipment (if applicable)?
- I have verified that there is sufficient space in the individual's home for the requested equipment:*
  
  YesN/A
- ITEM #10 INFORMATION:
- Item #10 Rationale
- Is the rationale for this item the same as any of the other items above?*
  
  YesNo
- What is the purpose of this equipment and how will the Individual benefit therapeutically?*
- Has the person been assessed with this type of equipment previous to this request?*
  
  YesNo
- How do you know it will work?*
- Who will set up and train the family or individual on the new equipment (if applicable)?
- I have verified that there is sufficient space in the individual's home for the requested equipment:*
  
  YesN/A
- ITEM #11 INFORMATION:
- Item #11 Rationale
- Is the rationale for this item the same as any of the other items above?*
  
  YesNo
- What is the purpose of this equipment and how will the Individual benefit therapeutically?*
- Has the person been assessed with this type of equipment previous to this request?*
  
  YesNo
- How do you know it will work?*
- Who will set up and train the family or individual on the new equipment (if applicable)?
- I have verified that there is sufficient space in the individual's home for the requested equipment:*
  
  YesN/A
- ITEM #12 INFORMATION:
- Item #12 Rationale
- Is the rationale for this item the same as any of the other items above?*
  
  YesNo
- What is the purpose of this equipment and how will the Individual benefit therapeutically?*
- Has the person been assessed with this type of equipment previous to this request?*
  
  YesNo
- How do you know it will work?*
- Who will set up and train the family or individual on the new equipment (if applicable)?
- I have verified that there is sufficient space in the individual's home for the requested equipment:*
  
  YesN/A
- ITEM #13 INFORMATION:
- Item #13 Rationale
- Is the rationale for this item the same as any of the other items above?*
  
  YesNo
- What is the purpose of this equipment and how will the Individual benefit therapeutically?*
- Has the person been assessed with this type of equipment previous to this request?*
  
  YesNo
- How do you know it will work?*
- Who will set up and train the family or individual on the new equipment (if applicable)?
- I have verified that there is sufficient space in the individual's home for the requested equipment:*
  
  YesN/A
- ITEM #14 INFORMATION:
- Item #14 Rationale
- Is the rationale for this item the same as any of the other items above?*
  
  YesNo
- What is the purpose of this equipment and how will the Individual benefit therapeutically?*
- Has the person been assessed with this type of equipment previous to this request?*
  
  YesNo
- How do you know it will work?*
- Who will set up and train the family or individual on the new equipment (if applicable)?
- I have verified that there is sufficient space in the individual's home for the requested equipment:*
  
  YesN/A
- ITEM #15 INFORMATION:
- Item #15 Rationale
- Is the rationale for this item the same as any of the other items above?*
  
  YesNo
- What is the purpose of this equipment and how will the Individual benefit therapeutically?*
- Has the person been assessed with this type of equipment previous to this request?*
  
  YesNo
- How do you know it will work?*
- Who will set up and train the family or individual on the new equipment (if applicable)?
- I have verified that there is sufficient space in the individual's home for the requested equipment:*
  
  YesN/A
- If any of the items being requested are considered medical equipment, has a denial from insurance/Medicaid been received? (If not applicable, choose "Other" and enter "n/a"):*
  
  YesNoOther
- Does any of the equipment being requested require installation and/or assembly, ie. climber, swing, etc.)?*
  
  YesNo
- What is the name of the equipment requiring installation and/or assembly?*
- 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.
- First and last name of individual signing the Release of Liability Waiver:*
  
  First NameLast Name
- Family Signature*
- Date*
  
  MonthDayYear
  Date
- 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):
- Please select authorization mode:*
  
  In person (family) signature requiredVerbal ApprovalWritten (email/text)
- Family Signature*
- Date of Family Authorization*
  
  MonthDayYear
  Date
- Comments:
- Equipment to be delivered to:
- Is the delivery address the same as the family's home address?*
  
  YesNo
- Name*
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Address*
  
  Street Address(Apt#/Suite#)
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Why is the delivery address is different than the family's home address?:*
- Therapist Name*
  
  FirstLast
- Therapist Title*
- Has the item(s) requested been trialed through the Cuyahoga DD Lending Library?*
  
  YesNo
- Agency Name*
- NPI#
- Agency Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Daytime Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Therapist Signature*
- Therapist Email :*
  example@example.com
- Submission Date*
  
  YearMonthDay
  Date
- Questions? Call the Cuyahoga DD Family Supports Coordinators at 216-736-2947
- Should be Empty:

2026 Equipment Request Form

Individual/Family Information

Equipment Requested:

Item #1 Rationale

Item #2 Rationale

Item #3 Rationale

Item #4 Rationale

Item #5 Rationale

Item #6 Rationale

Item #7 Rationale

Item #8 Rationale

Item #9 Rationale

Item #10 Rationale

Item #11 Rationale

Item #12 Rationale

Item #13 Rationale

Item #14 Rationale

Item #15 Rationale

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):

Equipment to be delivered to:

Family Authorization