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

Does this individual require ongoing support and care coordination to achieve stability and independence?* This field is required.

YESNO

4

Does this individual require personalized guidance and access to community services* This field is required.

YESNO

5

Has this individual been diagnosed with at least one of the following mental health or behavioral health challenges:

Mental Health Disorders

Substance Use Disorders

Intellectual and/or Developmental Disabilities (I/DD)

6

Does this individual have a Medicaid Tailored Plan through one of the following:

Partners Behavioral Health

Trillium

Vaya Health

8

Name* This field is required.

First Name

Last Name

9

Email* This field is required.

example@example.com

10

Phone Number* This field is required.

Area Code

Phone Number