Referrals Start Their Journey Refer Someone for Our Services Referral Form Name of Individual(Required) First Last Type of Referral(Required) Individualized Home Supports (IHS) with Training Individualized Home Supports (IHS) without Training 24-Hour Emergency Assistance Homemaking Services Integrated Community Supports (ICS) Chore Services Transitional Services Transportation Services Another Service Current Housing Type:(Required) Apartment/Home Nursing Assisted Living Group Home/Foster Home ICS Unhoused Home Address Street Address Address Line 2 City ZIP Code Email Address Phone Number(Required)Primary Disabilities(Required) Are there currently any animals living in the home of this referral?(Required) Yes No If yes, please specify: Does the individual have a Spenddown?(Required) Yes No Is the individual their own guardian/legal representative?(Required) Yes No If no, guardian/legal representative name and phone number: Hours Requested Per Day/Week:(Required) Any scheduling conflicts to work around?(Required) School/work/treatment/etc.Are there specific days or times during the week the individual prefers to meet?(Required) County of Residence:(Required) Date of Birth(Required) MM slash DD slash YYYY Gender Male Female Other County Social Worker Name: County Social Worker Phone:County Social Worker Email: Waivered Service: CADI DD TBI DD/SILS CDCS Other Gender preference of staff: Male Female No preference Other information that would be important to know in regards to this referral: