Know Someone with Special Needs?

Would you like to notify us of someone with special needs within Clermont County, Ohio? Please submit the form below. If you would prefer not to use our online form, we also have a PDF version that you can download, print and fill out.

Please note that any information you submit is subject to public records requests.

Please submit any questions, concerns or printed forms to:

John F. Kiskaden

Director
Clermont County Communications
jkiskaden@clermontcountyohio.gov
PH: (513) 732-7777
Fax: (513) 732-8045
2279 Clermont Center Drive, Batavia, OH 45103

Submit Online






What would you like to do? (choose one)

Input information for the first timeChange original informationPlease remove information


About the person with special needs:

Name of Special Needs Individual:

Primary Telephone for Residence:
(###-###-####)

Secondary Telephone for Residence:
(###-###-####)

Street Address (include apartment or lot number):

City:

State:

Zip Code:


Check All Boxes That Apply

Someone at this location is blind or visually impairedSomeone at this location has a cognitive impairment that can involve memory, language, thinking and judgement issuesSomeone at this location is hard of hearing or deafSomeone residing at this location is physically linked to equipment required to sustain his or her lifeSomeone residing at this location is bedridden, uses a wheelchair, or has a mobility impairmentSomeone at this location has a psychiatric impairmentSomeone at this location has a speech impairmentSomeone at this location may be using and electronic device for text communication utilizing a telephone line


Their Diagnosis

Diagnosis:

General Symptoms-Check All That Apply

Non-VerbalMedically FragileOn MedicationMedical Alert StatusSeizuresFlight RiskAggressive in New Situations May Hurt ThemselvesFears Flashing LightsFears Being TouchedFears Loud NoisesTourette's SyndromeExperiences Sensory OverloadBed Ridden

Is there any other helpful information you can share?


Your Information

Quite often, we have further questions about submissions that we receive or we would like to follow up with you. We do ask for an email address, but if you would like to be contacted by phone, please include that as well.
Your Name:

Your Email:

Your Phone:
(###-###-####)

If you have questions about the special needs form, contact Clermont County Communications Center 9-1-1 Director John Kiskaden at (513) 732-7777 or by e-mail jkiskaden@clermontcountyohio.gov