You Can Begin DRNJ's Intake Process by Completing the Form Below. You Can Submit the Form

Intake Form

You can begin DRNJ's intake process by completing the form below. You can submit the form even if you do not have all the information requested. After you submit your request, a member of DRNJ's intake staff should attempt to contact you within 5 days.

IMPORTANT: Please make sure you save the intake form and send us the updated file BEFORE you send it back to us. Your information will not save automatically.

Name of Person in Need of Assistance (client):

Street Address:

City, State, Zip:

County:

Home Telephone Number:

Work Telephone Number:

Cell Telephone Number:

Email Address:

Best way to contact you: ___ Home ___ Work ___ cell ____ email address

Best time to contact You:

Gender: Date of Birth:

Ethnicity: Race:Preferred Language:

List Disability(ies):

Registered with Perform Care: ____ Yes ____No or Registered with DDD: ____ Yes____No

Receives SSI/SSD: ____ None ______SSI ______SSDI _____ Both SSI and SSDI

Receives Medicaid/Medicare: ___ None ___Medicaid ___ Medicare ___Both Medicaid & Medicare

Highest Educational Level:Special Education: ____Yes _____No

Is another agency/organization or attorney assisting you with this matter? _____ Yes_____No

Is a member of your household a veteran? _____ Yes_____No

Referred by: (must provide for DVRS cases)

Guardian or Primary Contact-Please indicate which (skip if same as client)

Full Name of Guardian or Primary Contact:

Relationship to Client:

Address:

Contact information including telephone # and email:

Person Completing Form(skip if same as client)

Full Name of Person Completing Form:

Contact Info for Person Completing Form including address, telephone and email:

Relationship to client:

Please complete the next section ONLY if you have a special education issue, otherwise, leave blank.

Number of people residing in household:

Yearly Household Income (average is fine, for our grant reporting purposes only – no fees for our services):

Home School District:

Name of School Child Attends:

Child Study Team contact person and Telephone #:

When were the last evaluations done?

Have you requested re-evaluations or independent evaluations?

Accommodations (circle all that apply) None ASL Audio Tape Braille Environmental Sensitivity Large Print Low Literacy Note Taker Physical Access Reader Specific Language Interpreter TTY

Your relationship to child:

Description of Issue you want DRNJ to Address. (Please provide as much information as possible and include specific details regarding complaint.)

IMPORTANT: Please make sure you save the intake form and send us the updated file BEFORE you send it back to us. Your information will not save automatically.