Intake Form | Stark County Board of Developmental Disabilities

Applicant Information

First Name

Middle Name

Last Name

Previous Name(s)

Preferred Name

DOB

Residential Address

City, Zip

Email

Phone

Demographics

Gender

Race

Ethnicity

Primary Language

Secondary Language

Interpreter Needed

School Information

School Attending or Last School Attended

Grade

District

School Address

School Phone Number

Expected Graduation Date or Year Graduated

Diagnosis Information

Diagnosis of Developmental Disability

Physician

Name

Phone

Address

City, State, Zip

Psychologist/Psychiatrist

Name

Phone

Address

City, State, Zip

Other

Name

Phone

Address

City, State, Zip

Other Doctors/Hospitals/Specialists that may have records of diagnosis and/or treatment

Parent/Guardian Information

First Name

Last Name

Phone

Email

Address

City, State, Zip

Role

Child Protective Services (CPS) Involvement?