County Board of DD Referral

County Board of DD Referral Form

County Board of DD staff should use this form to refer individuals for services. If you have any questions, please call 740-702-4000 Ext. 144.

MM slash DD slash YYYY
Referral Made By (Your Name)(Required)
DD Board Making Referral(Required)
Individual Being Referred for Services(Required)
Individual's SSA(Required)
Waiver Type(Required)
Acuity(Required)