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 Street

City:

State

ZIP

County

Preferred Phone

Home Phone

Mobile

Work Phone

Best Time to Call

Gender

Other Gender Explanation

Ethnicity

Other Ethnicity Explanation

Race

African-American/BlackAmerican Indian/Native American/Alaskan NativeAsianCaucasian/WhiteNative Hawaiian/Pacific IslanderSome other raceTwo or more racesPrefer not to disclose

Race Explanation

Primary Language

Other Language

Do you need an interpreter?

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

African-American/BlackAmerican Indian/Native American/Alaskan NativeAsianCaucasian/WhiteNative Hawaiian/Pacific IslanderSome other raceTwo or more racesPrefer not to disclose

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)

How can we help?

Ohio Parent to Parent (P2P) Match Request - I am seeking to be matched with a peer that has been through a similar experience.Ohio Family to Family (F2F) Request - I am seeking to speak with a Family Support Specialist for information and resources in navigating systems.

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

email notifications

Contact Information