DD Service 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.
Which residential service(s) are you interested in?
Supervised Residential Home
Supportive Residential Home
Individualized Supportive Home
Independent Home
Which day service(s) are you interested in?
Day Habilitation (Site Based)
Day Habilitation Without Walls
Employment Services
Community Habilitation
Do you have any specific residence preferences?
All Male Home
All Female Home
Co-ed Home
Single Bedroom
Shared Bedroom
Other
List other preferences here:
Which area would you like to receive services in?
Bronx
Brooklyn
Staten Island
Manhattan
Queens
Rockland County
Westchester County
Orange County
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.
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Gender
Male
Female
Non-Binary
Prefer not to say
Primary Phone Number
Primary Mailing Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email Address
Primary Language Preferred
English
Spanish
Other
Has OPWDD Waiver Service Approval been obtained?
Yes
No
Current TABS Identification Number
Care Manager Name
First
Last
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)
Do you currently receive SNAP benefits? (If applicable)
Yes
No
Unknown
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
Do you have a history of seizures?
Yes
No
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.
Parent/Guardian Name
First
Last
Primary Phone Number
Relationship to person referred for services
Current Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
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
Select files
Max. file size: 32 MB, Max. files: 2.
Current Psychological Report
Max. file size: 32 MB.
Current Psychosocial Report
Max. file size: 32 MB.
Current Behavior Plan
Max. file size: 32 MB.
Current IEP (if applicable)
Max. file size: 32 MB.
Notice of Decision
Max. file size: 32 MB.
LCED
Max. file size: 32 MB.
Determination of Eligibility Letter or CR4 Form
Drop files here or
Select files
Max. file size: 32 MB, Max. files: 5.
Service Amendment Request Form (SARF)
Max. file size: 32 MB.
Current Physical w/PPD Read
Max. file size: 32 MB.
COVID-19 Vaccination Record
Max. file size: 32 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
Scroll to top