Form Dds-1 - Request For Developmental Disabilities Services
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5*06MP001E-001*
OKLAHOMA DEPARTMENT OF HUMAN SERVICES
Request for Developmental
Disabilities Services
Date
County
OKDHS case number
This form is used to apply for services to persons with developmental disabilities
through OKDHS Developmental Disabilities Services Division (DDSD). This application
does not address financial eligibility requirements for Medicaid funded DDSD services.
Section 1. Applicant
Applicant legal last name
First
Middle
Home phone
(
)
First
Middle
Street address
City
State
Zip
Also known as
Date of birth
Gender
Male
Female
Race
Home phone
Social Security number, attach copy of card
(
)
United States citizen
Resident alien
Yes
No
Yes
No
Marital status
Language spoken or understood by applicant
Married
Single
Divorced
Applicant employed
If yes, employer is
Yes
No
Completed by state employee only
Who has legal custody?
County of adjudication Adjudication date
Primary worker
Work phone
Supervisor
Work phone
(
)
(
)
If OKDHS or Office of Juvenile Affairs (OJA) has legal custody, attach copy of order.
Type:
Temporary
Permanent
Section 2. Parents/guardian
Father
Home phone
Work phone
(
)
(
)
Street address
City
State
Zip
OKDHS revised 12-15-2006
06MP001E (DDS-1)
Page 1 of 5
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