Service Referral Consumer Name:* First Last Consumer Date of Birth:*Diagnosis of consumer:*Contact Name:* First Last Email:* Phone Number:*What type of service are you interested in?* Select All Behavior Therapy Counseling Music Therapy Recreational Therapy If an opening is unavailable at this time for the service(s) you selected, do you wish to be placed on a waiting list?* Yes No When is the consumer available to receive services?* Day Time (2pm or earlier) After School (3pm-5pm) Evening (5pm-8pm) Weekends Do you currently have Medicaid Waiver Coverage?* Yes, we have Medicaid Waiver No, we do not yet have Medicaid Waiver We are in the process of getting Medicaid Waiver We need information about getting Medicaid Waiver What Indiana City do you need services in?*What Indiana County do you need services in?*Behaviors Needs/Goals:*Your Case Manager Name First Last Your Case Manager's Email Preferred Contact Email Phone When do you prefer to be contacted?Select Time8:00AM to 12:00pm12:00PM to 1:00PM1:00PM to 5:00PM5:00PM to 8:00PM
