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Multnomah County Intellectual & Developmental Disabilities Referral Form
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APPLICANT INFORMATION
This section should be completed about the person who is in need of services
Name
*
Your answer
Other names/aliases
Your answer
Date of Birth
*
Your answer
Gender
*
Your answer
Pronouns
Your answer
Race/Ethnicity
*
Your answer
Language spoken by client
*
Your answer
Intellectual or Other Developmental Disability Diagnosis
*
Intellectual Disability (IQ less than 75)
Autism
Cerebral Palsy
Down Syndrome
Epilepsy
Fetal Alcohol/Drug Effects
Traumatic Brain Injury (occurred prior to age 22)
Other:
Physical Address
*
Your answer
Mailing Address
Your answer
Phone number(s)
*
Your answer
Does the applicant receive SSI?
Yes
No
Clear selection
Health Insurance (i.e. OHP)
Your answer
Additional information you would like to share with us
Your answer
REFERRAL SOURCE
This section is about the person completing this form. A professional reference is not needed to apply for services.
Referrer Name
*
Your answer
Organization
Your answer
Referrer Phone
*
Your answer
Referrer Email
*
Your answer
WHO SHOULD WE CONTACT TO SCHEDULE THE INTAKE APPOINTMENT?
Contact Name
*
Your answer
Contact Language spoken
*
Your answer
Contact Phone number(s)
*
Your answer
Contact Email
*
Your answer
Relationship to applicant
*
Your answer
Is this person the legal guardian?
*
Yes
No
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