General Applicant Info

First name

Last name

Multi-line address

Country/Region

Address

City

Zip / Postal code

State/Province

Phone (Home)

Email

Phone (Cell)

County of Residence

Birthday

Month

Day

Year

Age

Birthplace (City/County/State)

US Citizen

How long have you been a resident of Kansas? (Years)

SSN

Medicaid?

Have you ever been determined eligible by another CDDO in Kansas?

If yes, in what county?

Primary Contact Info

First Name

Last Name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone (Home)

Phone (Cell)

Email

Relation to Applicant

Other Service System Info

Is the applicant currently accessing any other Waiver services?

Is the applicant a foster child?

Child Placing Agency

Case worker

Address

Phone/Email

Is the family Military?

ETS Date

Enrolled in TriCare E.C.H.O.?

Medical/Psychological Info

Disabilities (diagnosis)

Diagnosed by

Age of Onset

Disabilities (diagnosis)

Diagnosed by

Age of Onset

If Mental Retardation/Intellectual Disability is listed, does individual have a Psychological Evaluation made by a licensed professional who can make an independent DSM-5 diagnosis? (Although school psychologists may complete IQ testing, not all of them are licensed to diagnose).

DSM5

If yes, date of psychological evaluation

Location?

Visual Limitations

Describe

Hearing Limitations

Describe

Glasses?

Hearing Aids?

If Other, please describe

Is applicant able to read?

Comments

Current Living Situation

Living Situation

Family

Independent

Foster Home

Other (friends, crisis center, etc.)

Describe if other

Legal Status

Over 18 years old

Under 18 years old

Is applicant his/her own guardian?

Guardianship

Natural (child is under age 18)

Court-appointed, legal guardianship

If no, please fill out guardian name and contact information

Address

Phone

Email

Big Lakes CDDO requests tat you provide the following information, if applicable, when you submit your application. Please check documentation you have enclosed with the application. Failure to do so may result in a delay of determination being made.

Copy of Social Security Card

Most recent psychological evaluation and/or written documentation of diagnosis

Copy of Driver License/ID Card

Representation Paperwork

Copy of Medical Card

If currently a student, most recent IEP

My signature below verifies that I have read the information that the CDDO has provided, not only in this application, but also the various handouts and brochures I received. I have been provided the opportunity to contact the CDDO for more information or clarification regarding Intellectual/Developmental Disability (I/DD) Waiver services.

I understand that if I fail to provide the CDDO with disability-related diagnosis/medical documentation needed for eligibility determination purposes, case closure will result. Closed files may be reopened at any time upon request. The answers I have provided on this application are true to the best of my knowledge and ability.

Signature

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Parent/guardian signature is required if applicant is not age 18
Individual's signature is required if applicant is age 18+ (legal guardian may sign on behalf of applicant)

Big Lakes Developmental Center, Inc. CDDO will not reimburse individuals, families, and/or agencies for psychological evaluation fees, postage, faxes, long-distance phone calls, photocopying, travel costs, and/or any other expenses involved with providing the CDDO with eligibility determination documentation.

For more information about the Intellectual/Developmental Disabilities (I/DD) Waiver, visit the Kansas Department for Aging and Disability Services’ (KDADS) website:

Kansas Department for Aging and Disability Services