Get a Referral

Consent Statement

In order to process your request, we may need to share the information you provide with other agencies. Do you consent to give permission to share the information you provided? By selecting yes, you agree that you have read and understand Connect to Care’s privacy disclosure.*

Yes

Primary Contact

I am looking for information and services
I am looking for information and services for someone else, a care recipient

Care Recipient: General Information

First Name *

Last Name *

Street Address *

City *

State *

ZIP code *

County *

Home Phone *

Alternate Phone

Email Address

Care Recipient: Personal Information

Health Care Coverage

Date of Birth *

Gender

Ethnicity

Race

Primary Language

Has Served in the Military

Does not have a permanent/stable home

Related Issues

The referral recipient does not have a disability
The referral recipient has a disability (select all that apply)

Alternate Contact

No alternate contact necessary
Provide alternate contact

Step 1

Enter information on the individual needing assistance.

Step 2

Identify services you receive and/or services you are requesting.

Step 3

Confirm your information and submit your request.

Step 4

An Options Counselor will contact you by phone with information specific to your needs.

Consent Statement

Primary Contact

Relationship to Care Recipient*

Care Recipient: General Information

Care Recipient: Personal Information

Related Issues

Alternate Contact

Relationship to Care Recipient*

Interested in staying in touch?

Four easy steps

Step 1

Enter information on the individual needing assistance.

Step 2

Identify services you receive and/or services you are requesting.

Step 3

Confirm your information and submit your request.

Step 4

An Options Counselor will contact you by phone with information specific to your needs.

Consent Statement

Primary Contact

Relationship to Care Recipient*

Care Recipient: General Information

Care Recipient: Personal Information

Related Issues

Alternate Contact

Relationship to Care Recipient*

Interested in staying in touch?