Get Ddars Referral And Application Form

Completing the Ddars Referral And Application Form online is an essential step for individuals seeking services related to disability, aging, and rehabilitation. This guide will provide comprehensive, step-by-step instructions to assist you in filling out the form accurately and efficiently.

Follow the steps to complete the form online.

1. Click ‘Get Form’ button to access the Ddars Referral And Application Form and open it in your preferred editor.
2. Begin with Part 1 - Referral Information. Fill in your full name, including last, first, middle, and maiden names. Make sure to enter your date of referral in the specified format (month, day, year). Include your complete address, county, social security number, date of birth, sex, ZIP code, and telephone number. For the social security number, note that disclosure is mandatory to complete the form.
3. Provide details regarding your disability or diagnosis and the source referring you to this service. Include the telephone number of the referral source if applicable. Indicate whether you have a driver’s license and whether an interpreter is needed, particularly if you are deaf or non-English speaking. Specify if you can use public transportation.
4. Move on to Part II - Application/Description. Describe your disability and how it affects your daily living skills and specific work tasks. Explain how the services of the agencies will assist in achieving your goals and the anticipated impact on your family.
5. List the names and addresses of doctors or hospitals familiar with your disability or diagnosis, along with the date and type of your last exam. Describe any medical attention currently being received, including medications, therapies, and counseling.
6. Provide the name and relationship of one person who will know your address in case of a move, along with their contact information.
7. List schools you have attended, starting from the most recent, including the type of training received, the name of the school, its location, and any degrees or certificates earned.
8. Outline your employment history, starting with the most recent job. Include the name of the employer, city and state, job title, wages, and the reason for leaving each position.
9. For each job listed, note the specific work tasks you performed.
10. Identify any rehabilitation programs or agencies where you have previously received services. Provide the name and address of the facility or agency, as well as the dates and types of services received.
11. Finally, review and confirm consent for the release of information and check the services you are applying for. Sign and date the form where indicated. If applicable, ensure a second signature is provided for the parent or guardian.
12. Once all sections are completed, save your changes. You can then download, print, or share the completed form as needed.

Take the first step today and complete the Ddars Referral And Application Form online.