Empowering Individuals Consulting Referral Form for Individual Participant Services

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Use this form to request services provided to a specific individual or a specific individual's team. Please allow for approximately 15 minutes to complete this form. The beginning of the form will ask contact questions about the individuals support team members and the end of the form will request specifics about the individual you are requesting services for. This information will automatically then be put onto a waitlist for services and you will be contacted as services become available. Thank you for your time!

First Name (of individual to be placed on the waitlist for services)
*

Last Name
*

Preferred Name

Participant Identification Number (medicaid ID, client ID) if applicable:

Date of Birth
*

YYYY

Street Address
*

City
*

State
*

Zip Code
*

Phone Number

Funding *

Managed Care Organization

IRIS (Self-Directed Supports)

Private Pay

CLTS (Children's Long Term Support)

Other

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