Elevate Eligibility Questionnaire

1

Please verify that you are human* This field is required.

2

I am a...* This field is required.

Potential Client in Need of Service

Parent/Custodian/Caregiver Referring Someone I Take Care Of

Referring Agency/School/Community Organization Referring A Client

Other

3

Is the individual in need of services 16 years or older?* This field is required.

YESNO

4

Has the individual in need of service been diagnosed with at least of of the following mental health or behavioral health challenges:

Serious Emotional Disturbance (SED)

Serious Mental Illness (SMI)

Severe and Persistent Mental Illness (SPMI)

Severe Substance Use Disorder (SUD)

5

Does the individual in need of service have a Medicaid Tailored Plan through one of the following:

Partners Behavioral Health

Trillium

Vaya Health

7

Client/Patient's Name* This field is required.Please provide the first and last name of the individual in need of services.

First Name

Last Name

8

Contact Person's Name* This field is required.Please provide the first and last name of the individual

First Name

Last Name

9

Contact's Email* This field is required.

example@example.com