DEPARTMENT OF HUMAN SERVICES

Shawnie Rechtenbaugh, Department Secretary





DEVELOPMENTAL DISABILITIES
REHAB SERVICES
GUARDIANSHIP
LONG TERM SERVICES AND SUPPORTS
SERVICE TO THE BLIND
SOUTH DAKOTA DEVELOPMENTAL CENTER
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Referral Form

long term services and supports

Make an in Home Service Referral Form

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.
Referral's Information
Name
Address
Phone Number
 
Date of Birth
 
Gender
Language Spoken
Is this person aware a referral has been made?
Is this person capable of answering questions on their own behalf? If no, please provide an alternative contact.



Is this person currently hospitalized or been hospitalized within the last 3 days?
Does this person live alone
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
Name
Address
Phone Number
 
Email Address
* Required
Agency
Relationship to Referent