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
CONTACT US
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Referral Form

long term services and supports

Make a Referral

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?
Your Information Leave Blank If You Wish to Remain Anonymous
Name
Address
Phone Number
 
Relationship to Referent
Preferred Contact for Assessment If Different Than Listed Above
Name
Phone Number
 
Relationship
Please Summarize Reason for Referral:
* Required
Comments:
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.)