Community Integration Wait List & Referral Inquiry Form
Hit The Streets Corporation is a Medicaid waiver-approved provider offering Community Integration services to eligible individuals across Cuyahoga County. This form is used to submit a wait list inquiry referral request for individuals who may benefit from structured, non-clinical support focused on daily living, community connecting, and long-term stability. This inquiry may be submitted by individuals, families, referring professionals, including caseworkers and care coordinators. All submissions are reviewed to determine eligibility, availability, and program fit prior to enrollment.
Full Name
*
First Name
Last Name
Name of Person Completing This Form
*
First Name
Last Name
Email Address
example@example.com
Are you a caseworker or care coordinator?
*
Yes
No
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Does the individual currently have an approved Medicaid Waiver (e.g, Ohio home and Community-Based Services?
*
Yes
No
Not sure
What areas do you feel you need the most support in right now?
*
Daily living skills and routines
Community connection and engagement
Transitioning into stable housing
Life organization and stability
Aged out of foster care
Navigation community-based resources
Other
Please select a time that our Community Resource Supervisor can contact you
*
Submit
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