IDD Intake Form

Chester County Department of Mental Health/Intellectual and Developmental Disabilities

Intellectual and Developmental Disabilities Intake Form
All fields noted with "*" are required to be completed in order to submit an Intake. Once the required fields are completed, a submission button will be available.

If you are having difficulties submitting the Intake on-line, please call 610-344-6029 for assistance
Name of individual being referred
First Name:
Middle Initial:
Last Name:
DOB:

MonthDayYear
Preferred gender:
Primary Language:
Language(s) spoken at home
Is an Interpreter Needed?
ASL?*
Race:
Ethnicity:
Social Security Number
Is individual covered by private insurance?
Is individual covered under Medicaid?
Name of person completing this form:
Email Address:
Phone Number:
Format 000 00-0000Format: (000) 000-0000.
Relationship to referral:
School District: (If no longer in school, previously attended school district)
If Out of County or Out of State, name of school district:
Does the individual have a diagnosis of:
Reason for referral and/or any additional details:
Someone will be in touch in 3 – 5 business days. If this is an emergency, please call PA 211.
Should be Empty: