Intake Application

Intake Application

Welcome to the Defiance County Board of Developmental Disabilities. Please complete this form and provide supporting documents so that we can determine your eligibility for County Board assistance. For questions, please call (419) 782-6621.

Type of Application

A. Who referred you to the Defiance County Board of Developmental Disabilities?

B. Personal Information About the Applicant

Name
Name
First Name
Middle Name
Last Name
Address
Address
City
State/Province
Zip/Postal
Country

C. Developmental Disability (Occurring Prior to the Age of 22.)

D. Provide Required Proof of Qualifying Diagnosis/Condition (Please fax, mail, or drop off a copy of your records.)

E. Reasons for requesting county board assistance. (Needs/Concerns)

Checkboxes

F. Parent or Legal Guardian (Proof of any custody arrangements, adoption, or guardianship is required.)

Name
Name
First Name
Last Name
Relationship
Address (If different from the Applicant.)
Address (If different from the Applicant.)
City
State/Province
Zip/Postal
Country

For Office Use Only

Copies Obtained