Skip to main content
Provider Questionnaire

Use this form to submit your request to be included on the Clinton County Board of Developmental Disabilities provider’s page. You can view our entire provider list here. If at any time you want your information changed or removed please contact Leslee Culbert at 937-382-7519 x 1321.

Please attach a copy of your final certification letter from DODD and your agency logo or professional headshot photo.

Clinton County, Ohio Board of Developmental Disabilities Providers Submission Form

Required fields are marked with *

School Age
Transition
Adult
All Ages
Other
Anytime
Monday - Friday Daytime
Monday - Friday Evenings
Evenings Only
Daytime Only
Weekends Only
Other
Medically Fragile
Behavioral Needs
Autism
Dual Diagnosis
Other
-
-
-
-

X
Confirm
Cancel