UCCEDD Online Intake Form

Tell us about yourself:

Who may we thank for referring you to this form?

Other

Adult Section

First Name

Last Name

Your Relationship to Child with disability and/or special healthcare needs:

Other Relationship Explanation

Mailing Address

City:

State

ZIP

County

Email

Preferred Phone

Home Phone

Mobile

Work Phone

Best Time to Call

Gender

Other Gender Explanation

Ethnicity

Other Ethnicity Explanation

Race

Race Explanation

Primary Language

Other Language

Is an Interpreter Needed?

YesNo

How did you hear about Ohio Family to Family/Parent to Parent?

If Other Please Explain

Tell us about the child/person with disability and/or special healthcare needs:

Child Section

Child First Name

Child Last Name

Child Gender

Child Other Gender Explanation

Date of Birth

Premature?

YesNo

Weeks at birth?

NICU?

YesNo

NICU Weeks?

Child Ethnicity

Child Other Ethnicity Explanation

Child Race

Child Race Explanation

Does the child have a diagnosis/diagnoses?

YesNo

If so, when/where was diagnosis?

Who made the diagnosis?

Other diagnosis not listed below:

Primary Diagnosis

Child Primary Diagnosis Category:

Child Primary Diagnosis:

Secondary Diagnosis

Child Secondary Diagnosis Category:

Child Secondary Diagnosis:

Tell us about the issue you're having.

Primary Issue:

Further Description

Have you taken up this issue with anyone else? (ex. County Board, School, Physician)

Ohio Parent to Parent (P2P) Match Requested

Yes

Covid Related

YesNo

Primary Insurance (Hold CTRL to select multiple insurances)

Primary - If Other Please Explain

Secondary Insurance (Hold CTRL to select multiple insurances)

Secondary - If Other Please Explain

Contact Information