Eligibility Determination Application

The information given on this application assists in determining the applicant’s eligibility for services.  Such determination will be made in accordance with the HCP/CDDO Eligibility Determination policy.
 
General Information
 
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Services Requested
 

Disability Information
 

In order for the CDDO to determine if you meet eligibility requirements, it may be necessary to request information from previous placements, medical personnel, mental health personnel, schools, etc.

Please list below information about placements, treatment, testing, or evaluation: 
 
Hospitals

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Education
 
Please list the school or Special Education Cooperative that you have attended.

Check all that apply:
 
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Resource Information
 



Please list the name and address of any person who is assisting you with the application process: 
 
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Consent  & Agreement
 
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