Skip to content
Contact Us
Search for:
Who We Are
About Us
Staff
Board of Directors
Legacy Club
Newsletters
What We Do
Therapeutic Services
Recreation Therapy
Respite & Recreation
Speech Therapy
Physical Therapy
Social Skills
Spelling to Communicate
Community Employment
Project SEARCH
Bridge to Employment in Service and Tourism (B.E.S.T)
Community Living
Independent Living
Enabling Technology
Driving Simulator
Community Liaison
Asperger’s Support Group
Community Services
Get Services
Referral Form
Funding Resources
Get Involved
Events
Breakthrough Pro-Am Golf Tournament
Take Home the Cellar
Whiskey Business
Autism Acceptance Breakfast
Host an Event
Careers
Donate
Search for:
Get Services
Home
/
Get Services
Get Services
dslemp
2022-06-29T20:30:11+00:00
Referral Form
If you are interested in services, please fill out this referral form to receive more information.
Name Of Applicant:
(Required)
DOB:
(Required)
Name of person completing referral:
(Required)
Relationship to applicant:
(Required)
Please Select
Self
Parent
Sibling
Friend
Other
If other, please explain:
Reason for referral:
(Required)
Service Interest:
(Required)
Supported/Independent Living
Community services
Asperger Support Group
Job Services
Respite & Recreation
Therapeutic Services
Community Employment
Enabling Technology
Driving Simulator
Project SEARCH
Bridge to Employment in Service & Tourism (B.E.S.T.)
Select All
Medicaid Waiver:
(Required)
Please Select
Statewide Waiver
Self-Determination Waiver
Employment and Community First
In Process
None/I don't know
Phone Number:
(Required)
Email:
(Required)
Preferred Method of Communication:
(Required)
Phone call
Email
Text
Go to Top
