Provider Questionnaire

Complete the form to be added to our website

Add your business to our website

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 *

 

Agency/Independent Name:*
Contact Name:*
Address:
Phone:*
-
E-mail:*
Website:
Serving - Check all that apply:*
Availability - check all that apply
Specialty*
Please list any services that you are certified to provide by do not want to provide at this time:
Upload Final Certification Letter
Attach logo or professional headshot photo

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