DDD Application

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Applicant Name: First Middle Last

Birthdate: Gender & pronoun preference:

Address:

Mailing Address (if different):

Phone: Email:

Prefered Method of contact

Preferred person to contact if not the applicant:

Phone: Email:

First Time Applying?

Yes

Unknown

Currently receiving medicaid?

Yes

Currently receiving SSI/SSDI?

Yes

Diagnosis:

Intellectual/Cognitive Disability

Autism

Down Syndrome

Cerebral Palsy

Other:

What are your strengths? What do people like about you?

What things do you like to do? How do you spend your day?

Why are you applying for services from DDD?

What supports do you need to be successful?

What is your primary way to communicate?

Written language?

What language do you best speak/or understand?

Do you need a interpreter/translator?

Yes

Daily Life and Employment

Education:

Are you currently in school?

Yes

If yes, which school?

School Contact:

Do you have an IEP or 504 plan?

Yes

Do you have a signed diploma or a certificate of completion?

Yes

Do you have a GED?

Yes

Employment/Volunteering:

Are you currently working or volunteering?

Yes

if yes, where?

If no, are you interested in working?

Yes

Are you working in Vocational Rehabilitation?

Yes

Community Living:

Do you currently live:

On your own

With Family

With Roommates

How much time do you typically spend alone each day?

Are you interested in receiving residential supports?

Yes

If yes:

Round-the-clock services

Daily residential supports

Residential supports as needed

Safety And Security:

Legal Representative/Conservatorship-Check all that apply to the applicant if over 18 years old.

No Legal Representative in place

Court Ordered Legal Representative and type (Medical, limited, etc):

Court Ordered Conservator and Name if different from Legal Representative:

Power of Attorney and Type:

Please attach copies of the Legal Documents

Legal Representative Name: First Middle Last

Address:

Email Address:

Are you currently incarcerated?

Yes

Have you ever been involed with the police?

Yes

If yes, have any of these issues resulted in a misdemeanor or felony charges?

Yes

Healthy Living:

Do you use adaptive medical equipment?

Yes

If yes, please select below:

Walking Assistance (cane, walker, crutches)

Wheelchair

Adaptive bike or stroller

Standing devices

Mechanical Lifts

Orthotics

Specialized bed

Adaptive eating equipment

Other

Are you currently taking any medications?

Yes

If yes, please attach a medication list.

Understanding your behavioral health needs allows us to ensure that the most appropriate services and supports are in place for you to be successful. Please describe this information to the best of your ability. Your application will still be considered by DDD if this section is not completed.

What is the behavior?	Describe the behavior	How often does it happen?	What supports help me be successful?
Aggression towards others
Intentionally hurts self
Disruptive
Sexual Concerns
Running Away
Damaging Property
Other

I would like you to contact me/my representative to discuss these behaviors in more detail:

Yes

What is currently working well in your life?

What is not working? What is needed to improve?

Have you ever received services from DDD?

Yes

If yes, when and what services did you receive:

Which DD waiver or program are you interested in receiving services from?

Family Support 360

CHOICES

Strengthening Family

Respite Care

Community Training Services

What services or supports do you feel like you need to be successful? Please reference the service descriptions outlined on pages 12 and 13 of the Application Guide for DD Services:

Enter the code correctly below to submit your application