Referral Request Form This form is used to request information or submit a referral for community engagement services. Please do not include clinical details, diagnoses, Medicaid numbers, or other protected health information. Referring Party Information Name of Referring Party Email Address Phone Number Relationship to Individual Select Support Coordinator CSB Staff Family Member or Authorized Representative Other Individual Information Individual’s First Name First name only. Last Initial Age Range Select 18–25 26–35 36–50 51+ Service Interest Type of Support Being Requested (select all that apply) Community-Based Engagement Support with Social Connection Participation in Community Activities Exploration of Interests Outside the Home Brief Description of Support Goals Please describe general goals only. Do not include medical, behavioral, or diagnostic information. Coordination and Follow-Up Preferred Method of Contact Select Phone Email Requesting additional information prior to referral Submit Referral Request For privacy and confidentiality, please do not include clinical records, diagnoses, Medicaid numbers, or other protected health information.
