Consumer Information

Name of Person in Need of Assistance

Date of Birth


Current Age

County the individual lives in

Has the individual been found eligible for services through:
Early Intervention

The Department of Children and Families/PerformCare (DCF)

The Division of Developmental Disabilities (DDD)

Division of Vocational Services (DVRS)

I Don't Know

DCF/DDD ID Number

Is the individual Medicaid eligible?
Yes
No
I Don't Know

Contact Person's Information

First and last name of contact person

Phone

Email Address

Relationship to individual

Is another agency/organization or attorney assisting you with this matter presently
Yes
No
I Don't Know

If YES please list organizations(s) and contact person

Preferred Response

What Are You Having Difficulty With?

Please check the box that best fits your problem
Application or Eligibility for Services

Difficulty Accessing Services

Transition From School to Adult Life

SSI/Medicaid Eligibility

IEP

Education

Other

If OTHER please specify

Brief Description of Problem or Issue