Erie County Children's Single Point of Access Referral Supplemental Information use this link to open the Children's Single Point of Access (C-SPOA) Referral and "save as" to your computer to complete this fillable PDF or print and complete by hand.
**Formerly known as Erie County Community-Based Supplemental Referral Children's Single Point of Access Referral Supplemental Wraparound Referral.**
DSS2921 Service Application Booklet
PLEASE FILL OUT ONLY THESE SPECIFICED SECTIONS IN THE BOOKLET:
*Please note that the Cover Page is not Page 1 (Page numbers are listed in the upper, left-hand corner)
- Page 1, Section #3: Fill in the name and address of the parent who's completing the application
- Page 2, Section #6: Please list everyone in your household starting with yourself.
- Page 3, Section #7: Identify everyone in your household's race / ethnicity.
- Page 4, Section #8: Parent - sign your own name for each family member in the household as you are confirming they are citizens.
- Page 7, Section #15: This page looks at income coming into the home other than employment income. Please estimate if you do not have exact numbers.
- Page 9, Section #17: Enter employment information.
- Page 24 - Please sign and date booklet.
To print or download these instructions for the DSS2921 Service Application click here.
The SPOA required 6 sections to be completed from above have been highlighted in both applications. SPOA only requires you to complete these 6 sections, but all 25 pages of the application booklet must be submitted and Page 24 of the application must be signed and dated manually).
DSS2921 Service Application in English
DSS2921 Service Application in Spanish
Send completed DSS2921 Applications through one of the following methods:
- Mail to:
Erie County Department of Mental Health
ABP/C-SPOA/Suite 356
P.O. Box
Buffalo NY 14201 - DSS2921 Applications can also be dropped off in person to:
Appletree Business Park
Suite 356
2875 Union Road
Cheektowaga, NY 14227