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Eligibility Referral/Intake Form
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Email
*
Your email
Date of Request
*
MM
/
DD
/
YYYY
Your Name:
*
Your answer
Request Taken By (Associated County):
*
Auglaize
Champaign
Darke
Hardin
Logan
Mercer
Miami
Preble
Sandusky
Shelby
Union
Wyandot
Required
Which age category is referral?
*
COEDI
OEDI
Required
Name of Referral:
*
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
Social Security Number:
*
I have the number with me. Please enter social security number in "Other" category.
I do not have the number with me, but will get it to you.
Other:
Required
Address:
*
Your answer
Phone Number:
*
Your answer
Contact/Guardian Name:
*
Your answer
Gender:
*
Male
Female
Guardian Name:
*
Your answer
Guardian Email Address:
*
Your answer
Guardian is:
Self
Court-Appointed
Clear selection
Eligibility Type for C/FED Form (If Initial):
Your answer
Eligibility Type for C/FED Form (If Redetermination):
Your answer
Have services been received from a County Board before?
*
Yes
No
If you answered yes above, which County?
Your answer
Schools (Current/Past):
*
Your answer
Current Physicians (please list all):
*
Your answer
Current Situation:
*
Your answer
Other Agencies Involved:
*
Your answer
Comments (Observations of the request or situations such as urgency, complexities, and other issues that you feel are important).
*
Your answer
A copy of your responses will be emailed to the address you provided.
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