OR

AGES 5 AND OLDER

DDS ID #	8888

provider name:	Elizabeth Richardson Center	federal e.i. number	71-0355090

person’s name:

last	first	middle

birthdate:	sex:	race:	0-mixed 2-black 4-native american 6-spanish/latin 8-other

month	day year	m/f	1-asian 3-filipino	5-polynesian 7-white 9-unknown

medicaid number:	ssn:	county:

person’s developmental disability:	other:

01- intellectual disability	a-down syndrome

primary: ____ 02-cerebral palsy	b-fetal alcohol syndrome

03-epilepsy	c-spina bifida

04-autism	d-seizure disorder

05-other (specify A-Z or write in on `other’ line below)	e-cns infection

06-developmentally delayed (birth - 5 years)	f-cns trauma in skull fracture concussion

j-Chromosomal abnormalities

secondary: ____	k-Congenital Syndrome

l-Intra-uterine drug exposure

m-prenatal rubella

n-microcephaly

o-macrocephaly

p-metabolic disorder

q-visual impairment

other (specify)	r-hearing impairment

s-maternal aids

z-dually Diagnosed

adaptive behavior: ____

0-normal

1-mild intellectual disability

2-moderate intellectual disability

3-severe intellectual disability

4-profound intellectual disability

9-no instrument given

person’s mailing address:	city:	zip:
legal guardian’s name:	city	zip
mailing address:	city	zip

relationship of guardian: ___self ___parent ___relative ___advocate ___state agency ___other (specify) ____________________

date initial referral received:	date of current : ifsp/ipp	date of iinitial ifsp/ipp
date of initial evaluation:	date of current eval:	admission date:

send to:

developmental disabilities services-contract support

Fax Number: (501)-682-8656

P O Box 1437, Slot N202

Little Rock AR, 72203-1437