Potential Applicant
First Name
Middle Name
Last Name
Insurance
Yes
No
DoB
Gender
Male
Female
Other
Medicaid
Yes
No
County
Arkansas
Ashley
Baxter
Benton
Boone
Bradley
Calhoun
Carroll
Chicot
Clark
Clay
Cleburne
Cleveland
Columbia
Conway
Craighead
Crawford
Crittenden
Cross
Dallas
Desha
Drew
Faulkner
Franklin
Fulton
Garland
Grant
Greene
Hempstead
Hot Spring
Howard
Independence
Izard
Jackson
Jefferson
Johnson
Lafayette
Lawrence
Lee
Lincoln
Little River
Logan
Lonoke
Madison
Marion
Miller
Mississippi
Monroe
Montgomery
Nevada
Newton
Ouachita
Perry
Phillips
Pike
Poinsett
Polk
Pope
Prairie
Pulaski
Randolph
St. Francis
Saline
Scott
Searcy
Sebastian
Sevier
Sharp
Stone
Union
Van Buren
Washington
White
Woodruff
Yell
DDS ID
Is a Twin
Yes
No
Address
City
State
AR
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
Parent/Guardian
--Select a Type--
Mother
Father
Legal Guardian
Relative
Grand Parent
Foster Parent
Step Parent
Other
Primary Caregiver
Yes
No
First Name
Middle Name
Last Name
Suffix
Sr
Jr
III
Home
Cell
Work
Ext
Fax:
Email
Address same as applicant
Yes
No
Mailing Address is the same
Yes
No
Address
City
State
AR
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
Referral Source
Referral Source
Hospital
Physician
Health Department
DCFS
Parent / Legal Guardian
Friend
School
Daycare
Relative
Early HEAD Start
Homeless Shelter
Mental Health
Other
Social Security
Therapy Provider
Dennis Development Ctr
Foster Parent
Infant Hearing Program
Early Intervention Day Treatment Centers
WIC
Home Visiting Program
Children with Chronic Health Conditions (CHC)
EIDT Enrollment Status
Enrolled
Screening Still in Progress
Not Eligible for EIDT Services
Discharged/Exiting EIDT Services
Received First Connection approved information/handout?
Yes
No
Requestor
Name
Phone
Email Address
Reason for Request
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