Children’s Extraordinary Needs Program Waitlist Request Form

The Children’s Extraordinary Needs (CEN) Program is operated by the Oregon Office of Developmental Disabilities Services (ODDS). The CEN Program is for children under 18 with very high medical or behavior needs. Parents and guardians can be paid to provide care to their enrolled child. Due to limited funds, the program has a waitlist.


To be added to the CEN waitlist, complete and submit the CEN waitlist request form. ODDS will notify the parent or guardian once your child has been added to the CEN waitlist. If you have any questions regarding your submission, email cenprogram@odhs.oregon.gov.





Not all fields are *required, however, we ask that you please complete as many optional fields as you are able.

Referral Source

What is your relationship to the child that you are submitting a referral request for?*

Person submitting referral

Person submitting referral

Person submitting referral

Person submitting referral

Phone

Child’s Personal Identification Information

Does the child have a Guardian that is not a Parent?*
Is the child currently eligible for DD services?
Is the child enrolled in ODDS Children’s Residential Services?
Is the child enrolled in ODDS Children’s Intensive In-home Services (CIIS)?


Also referred to as Oregon Medicaid ID number

Child's Contact Information

Does the child's have the same address as their Parent(s)/Guardian(s)?*
Child's current living arrangement
Select
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Child's Identity Expression (OPTIONAL)

So that we may more successfully support this child, please let us know more about how they identify.

Select or enter value
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(Select all that apply)

What is the child's gender assigned at birth?


The sex, male, female or intersex, that a doctor or midwife uses to describe a child at birth based on their external anatomy.


External appearance of one's gender identity, usually expressed through behavior, clothing, body characteristics or voice, and which may or may not conform to socially defined behaviors and characteristics typically associated with being either masculine or feminine.

Family or Guardian Information

Parent/guardian

Parent/guardian

Select
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Parent/guardian

Parent/guardian

Phone

Parent/guardian

Parent/guardian

Select or enter value
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Would you like to add contact information for a second parent or guardian for this child?*

Parent2 y/n

Parent Information #2

Guardian Information #2

Does the parent/guardian have the same address as the parent/guardian above?*

Parent2 Res y/n

Parent/guardian #2

Parent/guardian #2

Parent/guardian #2


Please include physical address and P.O. box (if applicable)

Parent/guardian #2

Parent/guardian #2

Select
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Parent/guardian #2

Parent/guardian #2

Phone

Parent/guardian #2

Parent/guardian #2

Select or enter value
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Would you like to add contact information for an additional parent or guardian for this child?*

Parent3 y/n

Parent Information #2 (3)

Guardian Information #2 (3)

Does the parent/guardian have the same address as any individuals listed above?*

Parent/guardian #3

Parent/guardian #3

Parent/guardian #3


Please include physical address and P.O. box (if applicable)

Parent/guardian #3

Parent/guardian #3

Select
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Parent/guardian #3

Parent/guardian #3

Phone

Parent/guardian #3

Parent/guardian #3

Select or enter value
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Service Coordinator(s) Information

County Developmental Disability Provider (CDDP)

Select
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Phone

ODHS Developmental Disabilities Services Coordinator

Phone
Phone

ODHS Child Welfare Services Coordinator


(if different than the DD coordinator above)

Phone
Phone
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