Form Dds-1 - Request For Developmental Disabilities Services Page 3
ADVERTISEMENT
1
2
3
4
5Request for Developmental Disabilities Services
06MP001E (DDS-1)
1. Briefly describe any significant medical problems/disabilities experienced by applicant.
2. Who is applicant's current primary care physician?
3. Does applicant take any routine medications?
Yes
No
If yes, list medications, dosage, and reason for medications.
4. Has applicant been diagnosed with mental retardation, autism,
or mental illness?
Yes
No
If yes, list diagnosis
When
By whom
5. Has applicant had a psychological evaluation?
Yes
No
Attach copy, if available.
If yes, when
Where
By whom
I.Q.
Mental age
Describe any behavioral problems:
Section 5. Education
Is applicant currently attending school?
Yes
No
If yes, where
Special class
Regular class
Grade
Copy of applicant's current individualized education plan (IEP) available?
Yes
No
If yes, attach copy.
If out of school, where did applicant attend school?
OKDHS revised 12-15-2006
Page 3 of 5
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal