IDD Specialist Intake Form
Type of Eligibility Needed:
*
DD Eligibility (For youth under 18)
DDD (For youth 18 or older)
Consult Only
NAME:
*
D.O.B.:
*
Is the Youth in an Out of Home Treatment Facility?
*
Yes
No
CYBER ID (IF APPLICABLE):
Date of Referral:
*
/
Month
/
Day
Year
Date
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:
*
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Evaluations & Documentation & Guardianship
Name:
Date of Birth
-
Month
-
Day
Year
Date
CYBER ID
Please Indicate Below the Evaluations that have been completed for the youth:
*
Psychological/Education
ADOS/CARS
Neurodevelopmental
Year of Psychological/Educational Evaluation
*
Year of ADOS/CARS Evaluation
*
Year of Neurodevelopmental Evaluation
*
Year of 'Other' Evaluation
*
Is the Youth Medicaid Eligible?
*
Yes
No
Is the Youth's Birth Certificate Available/Accessible?
*
Yes
No
Is the Youth's Social Security Card Available/Accessible?
*
Yes
No
Is a Photo ID for the Youth Available?
*
Yes
No
Does the Youth have a Medicaid/SSI Award Letter Available?
*
Yes
No
Guardianship Status?
*
Youth is their own guardian
Parent/Caregiver has guardianship
Youth has a state appointed guardian/DCPP
Guardianship is pending
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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:
*
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