DEPARTMENT OF HUMAN SERVICES


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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 a Referral

Information on person needing services (consumer):
Name:
Address:
City:
State:
Zip Code:
Phone:
Date of Birth: or Age:
Gender:
 
Language Spoken:  
Is this person aware a referral has been made:
 


Your Information

 

Name: Anonymous
Address:  
City:  
State:  
Phone:
Email:

Relationship to Referent:

 

 

Preferred Contact for Assessment (if different than listed above):

 

Name:  
Phone:
Relationship:  
Please Summarize Reason for Referral (mandatory):
Comments:
 
Please complete the Captcha box below so we know you're a real person

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.)