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
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?