Initial Agency
Date:
( Early Intervention
( Local School District
( Division of Developmental Disabilities
State of New Jersey

Departments of Health, Education and Human Services

INITIAL UNIFORM APPLICATION

FOR SERVICES TO INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES 21 AND UNDER

Complete pages 1 and 2 of this Application.

Applicant:
First	Middle	Last
Date of Birth:	Social Security Number:
Voluntary Per The Privacy Act of 1974 (P.L. 93-579)
Parent/Legal Guardian Information:

Name(s):	Relationship:
Address:	P.O. Box/Apt #
City, State, Zip:
County:	Local School District:
Home Phone No:	Work Phone No:	(for)
What type of assistance are you seeking?

I wish this initial uniform application to be used to apply for the following services (check all that apply):

Early Intervention Services

Special Education Services through my local school district

Division of Developmental Disabilities Services

INITIAL UNIFORM APPLICATION

Continued

In accordance with New Jersey P. L. 2000, c. 112, each subsequent agency may ask for additional information to complete its eligibility determination. Information and documents that are provided to each agency about the applicant shall be kept confidential unless the parent/legal guardian states in writing that specific pieces of information may be shared.

Signatures, Notice and Consent to Release Information: (Complete A, B and C if you are applying for services from more than one Department. Complete C if you are applying to only one Department)

A.	I understand that this initial application will be forwarded by:
(Initial Contact Agency)
to all of the agencies I have indicated on page one. I further acknowledge that this initial application may be forwarded to any additional agency participating in the Initial Uniform Application in the future that I direct.

B.	I further consent for	(Initial Contact Agency)
to release to	(Agency(s)) the following documents:
If you are consenting to the release of Education and/or Early Intervention records, please check that you have received one or both of the following parental rights literature regarding confidentiality and access to educational or early intervention records.

Parental Rights in Special Education

Family Rights in Early Intervention

C.	Signatures:
Signature of Applicant or Authorized Individual *
Date
Signature of Witness, if Appropriate **
Date
Signature of Person Accepting Application
Agency
Phone
*For individuals under 18 years old: Authorized individual is the parent or legal guardian.

*For individuals 18 years old or older: The applicant is required to sign or make a mark where indicated, unless there is a legally appointed guardian. **If an applicant only makes a mark, a witness must sign on the second line.

Initial Uniform Application sent to the following agencies:

1.	Date:
2.	Date:

INITIAL UNIFORM APPLICATION

Continued

AGENCY DESCRIPTIONS

Early Intervention System (EIS)

Department of Health (NJDOH)

Who is eligible? Children, from birth up until three years of age, that meet the following criteria: 1) developmental delay of 25% in two or more developmental areas, 2) developmental delay of 33% in one developmental area, or 3) a medically diagnosed physical or mental condition that has a high probability of resulting in a developmental delay. Developmental areas include cognitive; physical including gross motor, fine motor, vision and hearing; communication, social/emotional or adaptive.

Services Available: The goal of EIS is to support families in helping their children learn, play and develop to their fullest potential in their natural environments. Natural environments are the home and community settings, in which children with and without disabilities live and play together. Once a child has been determined to be eligible for services from EIS, an Individualized Family Service Plan (IFSP) is developed. The IFSP is a written document that identifies services that are needed by the child and family and how those services will be implemented. The IFSP may include specialized instruction, speech and language therapy, physical therapy, occupational therapy, family training and counseling, and other services needed by the child and family. Certain required services, such as referrals, eligibility determinations, service coordination and IFSP development and review are provided at no cost to the family. Beyond these services, a family may have to assume some or all of the costs, depending on resources available to the Department and the parents’ ability to pay. Family rights with respect to EIS include, but are not limited to, the right to say no to some services and to choose only the services wanted, the right to be involved with the decisions made concerning their child, the right to the development of an IFSP within 45 days of the date the child is referred if he or she is found eligible for services and the right to receive services listed in the IFSP.

General Information: For additional information about EIS, refer to the Internet at the Department of Health (NJDOH) Website www.nj.gov/health/fhs/eiphome.htm or call NJDOH-EIS at 609-777-7734.

Special Education Services

School Services for Students with Disabilities, Ages 3-21

Department of Education

Who is eligible? A student shall be eligible for special education services when it is determined that the student has one or more of the disabilities (physical, hearing, vision, communication, cognitive, neurological, social and emotional) defined in special education regulations, N.J.A.C. 6A:14-3.5(c)1-13; the disability has an adverse effect on his or her educational performance and the student requires specialized instruction. A multi-disciplinary team of school personnel and other professionals shall conduct an initial comprehensive evaluation upon written consent of the student’s parents. Based upon the initial evaluation, members of the child study team, school personnel, the child’s teacher, other professionals and parents shall meet to discuss and develop an individualized education program (IEP) that specifies needed services for the student.

Services Available: Services are provided at no cost to families in accordance with the student’s IEP. Services include specialized instruction and related services that are needed for the student to benefit from educational instruction. Related services may include such developmental, corrective and other supportive services, such as speech therapy, counseling, physical therapy, and occupational therapy, as are required to assist a child with a disability to benefit from special education.

General Information: For additional information, refer to the Internet at the Department of Education Website http://www.state.nj.us/njded/specialed/index.html.

INITIAL UNIFORM APPLICATION

Continued

Division of Developmental Disabilities

Department of Human Services

Who is eligible? In order to be eligible for services, an individual must be a resident of New Jersey and have a developmental disability that meets the Division’s definition. The Division defines developmental disability as a severe chronic disability of a person that meets all of the following:

( Is attributable to a mental or physical impairment or combination of mental or physical impairment, other than mental illness; and

( Is manifested before the age of 22; and

( Is likely to continue indefinitely; and

( Results in substantial limitations in at least 3 or more of the following 6 major life activities (For an individual under age 18, the following factors shall be evaluated according to expectations based upon the individual’s age.)

( Self-care

( Communication (Receptive and Expressive Language)

( Learning

( Mobility

( Self-direction

( Capacity for independent living and economic self-sufficiency; and

( Reflects the need for a combination and sequence of special interdisciplinary or generic care, treatment or other services which are lifelong or extended duration and are individually planned and coordinated.

( Developmental disability includes but is not limited to severe disabilities attributable to mental retardation, autism, cerebral palsy, epilepsy, spina bifida and other neurological impairments where the above criteria are met.

The Division may have additional requirements for eligibility for particular Division services that will be explained more fully to you when you request those specific services. Individuals and their families who are found eligible for certain services may be required to contribute to the cost of those services. Information about contribution to the cost of services will be explained more fully to you when you request those specific services.

Services Available: The Division offers a variety of programs, supports, and services to help meet the care, training, psychological, social, vocational, health and other important needs of eligible individuals. The Division offers these services based upon the varying levels of ability of the individual. In general, the individual or his or her parent or legal guardian must request a specific service before the Division will determine whether the individual is eligible for that service. The individual will be assigned a case manager who may be contacted to request and explain the services available. Services include, but are not limited to, case management, in- and out- of home respite care, cash subsidy to purchase specified services, provision of assistive devices, options for residential services and vocational training and employment programs. Many of these services are provided through contracts with private organizations or individual contractors. Programs and services are available as the Division’s resources permit so an individual who is otherwise eligible may have to wait for services.

General Information: For additional information, refer to the Internet at the Department of Human Services Website http://www.state.nj.us/humanservices/ddd/home/index.html or call DDD at 1-800-832-9173.

FHS-16

JUL 12	Page 3 of 4 Pages.

FHS-16, Uniform Initial Application for Services to Individuals with Developmental Disabilities 21 and Under

FHS-16, uniform initial application, services, developmental disabilities, age 21 and under, education, human services, dhss, family health services, FHS

ewhite

2002-07-22

njdoh