Consumer Information Name of Person in Need of Assistance Date of Birth JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 01020304050607080910111213141516171819202122232425262728293031 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 EmailPhoneFaxMail 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
