If you know of an individual who may benefit from receiving services provided by the Division of Long Term Services and Supports, complete the Referral Form by providing information about the individual, his or her contact information and the type of assistance needed. A Long Term Services and Supports Specialist will contact the individual to follow up on the referral.
Your Information Leave Blank If You Wish to Remain Anonymous
Relationship to Referent
Preferred Contact for Assessment If Different Than Listed Above
Please Summarize Reason for Referral:
By completing this form, you are affirming that the information you are submitting has been examined by yourself, and to the best of your knowledge and belief, is true and correct. (If you wish to remain anonymous, you do not need to provide your name, phone number or email address.)