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.
Diagnosis(es) or Chronic Medical Conditions:
Services being requested:
Additional details that support this referral:
Your Information Leave Blank If You Wish to Remain Anonymous
Relationship to Referent