Access Coordination Intake - Mid-Island Y JCC

Individual Full Name *

Individuals Date of Birth

Parent/Legal Guardian Name

Phone Number

Home Address

Street

City

State

Zip

Email Address

Gender

Age

Primary Diagnosis

Secondary Diagnosis

OPWDD TABS # (if applicable)

Does the Individual currently have active Medicaid?

Medicaid # (if applicable)

OPWDD eligibility status

Care Coordinator Agency

Care Coordination Name, Phone and Email

Current School/Agency/Program(s). including Contact Person/Info

Initial Request. What are some of the issues that bought you here? What services are you requesting?

What time will you be available?

Mornings 8am - 12pm

Afternoons 2pm - 6pm

Evenings 7pm - 9m

Employment/Classroom Setting

Type of Contact

Phone

Email

Meeting

OtherOther

How did you hear about our service?

Hebrew Education Society

Shorefront Y

Adler Center For Special Needs @ Mid Island Y JCC

Sid Jacobson JCC

Barry and Florence Friedberg JCC

Commack JCC

OtherOther