Developmental Disabilities Services: Intake Form

The Foundling provides support for people with developmental disabilities throughout the New York metropolitan area, reaching more than 850 adults and children every year. Our programs create a supportive and nurturing environment, helping the people we support strive toward independence and become thriving members of their communities. To begin the process of receiving services at The New York Foundling, we kindly ask that you complete this intake form.

Program/Service Selection

The people we support can participate in one or all of these services depending on their needs and goals. We would like to know which services interest you at The Foundling.

List other preferences here:

Referral Source

We would like to know who has referred you to The New York Foundling for services.

Name of referring agency

Name of contact person

Email

Phone

Personal Information

This section is for the person being referred for services.

Date of Birth

Primary Phone Number

Email Address

Current TABS Identification Number

Care Manager Phone

Care Manager Email

Benefits Information

We want to ensure you have the proper benefits awarded to you to receive OPWDD eligible services.

Social Security Number

Medicaid Number

Medicare Number (if applicable)

Medical History

Providing a complete medical history will help us ensure you receive the appropriate services.

Relevant medical conditions or diagnosis

Primary medical doctor name/practice name

Primary Medical Doctor Phone Number

Any known allergies?

Current list of medications

Do you have a history of any risk factors or out of home placement? (hospitalization history, suicidal/homicidal ideation or attempted history)

Adaptive Behavior

Learning more about your capabilities will help us identify the services that are appropriate.

Please describe your communication ability

Please describe your level of mobility

Please describe your capacity for independent living

Guardian Information

Please complete for the person who will be point of contact regarding care.

Primary Phone Number

Relationship to person referred for services

Email Address

Supporting Documentation

Please upload the following documents necessary to begin the enrollment of services. Please take your time to ensure you submit the correct items.

Current Life Plan

Drop files here or

Max. file size: 50 MB, Max. files: 2.

Current Psychological Report

Max. file size: 50 MB.

Current Psychosocial Report

Max. file size: 50 MB.

Current Behavior Plan

Max. file size: 50 MB.

Current IEP (if applicable)

Max. file size: 50 MB.

Notice of Decision

Max. file size: 50 MB.

LCED

Max. file size: 50 MB.

Determination of Eligibility Letter or CR4 Form

Drop files here or

Max. file size: 50 MB, Max. files: 5.

Service Amendment Request Form (SARF)

Max. file size: 50 MB.

Current Physical w/PPD Read

Max. file size: 50 MB.

COVID-19 Vaccination Record

Max. file size: 50 MB.

Thank you for completing our Intake Form. A member of our staff will evaluate this intake form and respond to you within 48 hours.
Having trouble uploading any documents? Please send them to us at I&R@nyfoundling.org

DD Service Intake Form

Program/Service Selection

Referral Source

Personal Information

Benefits Information

Medical History

Adaptive Behavior

Guardian Information

Supporting Documentation