Intake - LADD Inc.

Intake Form

Disclaimer: Thank you for your interest in receiving services from LADD. This form is used to collect information about receiving LADD services only and is to be kept confidential.

PERSONAL INFORMATION

Legal Name(Required)

First Middle Last

Preferred Name

First

Gender(Required)

Male

Female

Non-binary

Other

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Birth Date(Required)

RELATIONSHIP INFORMATION

Name of Person Filling Out Form

First Last

Relationship to Person Requsting Services

Are you the guardian of the person requesting services?

Phone

SERVICE INFORMATION

Do you get Developmental Disability Services?

IF NO, SKIP TO THE NEXT SECTION

County of Service

Do you have a Waiver?

What kind of Waiver do you have?

Have you discussed getting LADD Services with your SSA?

What is your SSA's Name?

First Last

SSA's Email

SSA's Phone Number

Please ask your SSA send us a referral at intake@laddinc.org

DIAGNOSIS INFORMATION

LADD only provides services for people who are eligible for Developmental Disability Services. A developmental disability is defined in federal and state law as a severe and chronic disability attributable to a mental or physical impairment other than mental illness, manifested before age 22, likely to continue indefinitely, and resulting in substantial functional limitation in major life activities.

What is your Developmental Disability Diagnosis?

Do you have documentation of your developmental disability?

THIS CAN INCLUDE SCHOOL, MEDICAL, AND/OR PYSCHOLOGICAL REPORTS.

To get services from LADD you need to work with Hamilton County Developmental Disabilities Services Introduction and Eligibility Department. They can be reached at: (513)559-6990 or https://www.hamiltondds.org/services/eligibility/

SERVICE REQUEST

Please tell us what services you are looking for make sure to include days and hours you are requesting services for.

How did you hear about us?

SUBMISSION

Please click submit to request services.

Intake Form

PERSONAL INFORMATION

RELATIONSHIP INFORMATION

SERVICE INFORMATION

DIAGNOSIS INFORMATION

SERVICE REQUEST

SUBMISSION

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