2023 Equipment Request Form

2023 Family Supports Equipment Request Form
PLEASE NOTE: All 2023 Equipment Request Forms must be submitted by Friday 12/8/23.
(To be completed by an OT, OTA, PT, PTA, SLP, Licensed Physician, OR Cuyahoga DD Staff)
Individual/Family Information
Individual Name*

First NameLast Name
D.O.B*

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

MonthDayYear
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
Medical equipment, trampolines, pools, spas, saunas, items of general utility (dining room chair, toothbrush, etc.), items solely for entertainment or recreational purposes, and devices used for the sole purpose of restricting movement or function cannot be purchased under the Family Supports Program.
Equipment Requested:

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

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

12345678910
Item #1 Info:
Equipment #1 Rationale
What is the purpose of this equipment and how will the Individual benefit?*
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:
Equipment #2 Rationale
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?*
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:
Equipment #3 Rationale
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?*
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:
Equipment #4 Rationale
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:
Equipment #5 Rationale
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:
Equipment #6 Rationale
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:
Equipment #7 Rationale
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:
Equipment #8 Rationale
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:
Equipment #9 Rationale
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:
Equipment #10 Rationale
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*

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*

Clear
Date of Family Authorization*

MonthDayYear
Date
Comments
Equipment to be delivered to
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*

YearMonthDay
Date
Therapist Email*
example@example.com
Questions? Call NEON 1-800-237-6828
Should be Empty:

2023 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