Cuyahoga DD Family Supports Equipment Request Form

2023

Individual Name*

First NameLast Name

D.O.B*

Date

Weight of Individual

Height of Individual (feet/inches)

Date of assessment*

Date

Diagnosis*

Parent/Guardian Name (Enter N/A if not applicable)*

Parent/Guardian/Individual Contact Email Address*

example@example.com

Parent/Guardian/Individual Phone Number*

Please enter a valid phone number.

Family Address*

Street Address (Apt.#/Suite#)

Street Address Line 2

CityState / Province

Postal / Zip Code

Please upload item(s) picture and quote (if applicable)

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How many items/equipment need purchased? (Select only 1 box)*

Item #1 Info:

What is the purpose of this equipment and how will the Individual benefit?*

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

I have verified that there is sufficient space in the individual's home for the requested equipment*

YesN/A

Describe the home's/apt.'s usable space

Item #2 Info:

Is the equipment rationale the same as the equipment listed above?

YesNo

What is the purpose of this equipment and how will the Individual benefit?*

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

I have verified that there is sufficient space in the individual's home for the requested equipment*

YesN/A

Describe the home's/apt.'s usable space

Item #3 Info:

Is the equipment rationale the same as the equipment listed above?

YesNo

What is the purpose of this equipment and how will the Individual benefit?*

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

I have verified that there is sufficient space in the individual's home for the requested equipment*

YesN/A

Describe the home's/apt.'s usable space

Item #4 Info:

Is the equipment rationale the same as the equipment listed above?

YesNo

What is the purpose of this equipment and how will the Individual benefit?*

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

I have verified that there is sufficient space in the individual's home for the requested equipment*

YesN/A

Describe the home's/apt.'s usable space

Item #5 Info:

Is the equipment rationale the same as the equipment listed above?

YesNo

What is the purpose of this equipment and how will the Individual benefit?*

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

I have verified that there is sufficient space in the individual's home for the requested equipment*

YesN/A

Describe the home's/apt.'s usable space

Item #6 Info:

Is the equipment rationale the same as the equipment listed above?

YesNo

What is the purpose of this equipment and how will the Individual benefit?*

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

I have verified that there is sufficient space in the individual's home for the requested equipment*

YesN/A

Describe the home's/apt.'s usable space

Item #7 Info:

Is the equipment rationale the same as the equipment listed above?

YesNo

What is the purpose of this equipment and how will the Individual benefit?*

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

I have verified that there is sufficient space in the individual's home for the requested equipment*

YesN/A

Describe the home's/apt.'s usable space

Item #8 Info:

Is the equipment rationale the same as the equipment listed above?

YesNo

What is the purpose of this equipment and how will the Individual benefit?*

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

I have verified that there is sufficient space in the individual's home for the requested equipment*

YesN/A

Describe the home's/apt.'s usable space

Item #9 Info:

Is the equipment rationale the same as the equipment listed above?

YesNo

What is the purpose of this equipment and how will the Individual benefit?*

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

I have verified that there is sufficient space in the individual's home for the requested equipment*

YesN/A

Describe the home's/apt.'s usable space

Item #10 Info:

Is the equipment rationale the same as the equipment listed above?*

YesNo

What is the purpose of this equipment and how will the Individual benefit?*

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

I have verified that there is sufficient space in the individual's home for the requested equipment*

YesN/A

Describe the home's/apt.'s usable space

Does any of the equipment being requested require installation and/or assembly, ie. swing set)?*

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*

Clear

Date*

Date

Please select authorization mode*

In person (family)signature requiredVerbal ApprovalWritten (email/text)

Family Signature*

Clear

Date of Family Authorization*

Date

Comments

Name*

First NameLast Name

Address*

Street Address(Apt#/Suite#)

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Therapist Name*

FirstLast

Therapist Title*

Agency Name*

NPI#

Agency Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Daytime Number*

Please enter a valid phone number.

Therapist Signature*

Clear

Therapist Email :*

example@example.com

Submission Date*

Date

Therapist Email*

example@example.com

Family Supports Equipment Request Form

Individual/Family Information

Equipment Requested:

Equipment #1 Rationale

Equipment #2 Rationale

Equipment #3 Rationale

Equipment #4 Rationale

Equipment #5 Rationale

Equipment #6 Rationale

Equipment #7 Rationale

Equipment #8 Rationale

Equipment #9 Rationale

Equipment #10 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 Supports Equipment Request Form

Individual/Family Information

Equipment Requested:

Equipment #1 Rationale

Equipment #2 Rationale

Equipment #3 Rationale

Equipment #4 Rationale

Equipment #5 Rationale

Equipment #6 Rationale

Equipment #7 Rationale

Equipment #8 Rationale

Equipment #9 Rationale

Equipment #10 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