Please fill out this referral form if you will be using CDCS. CDCS is Consumer-Directed Community Supports
CDCS
Please Select
CDCS
Is the Client transferring from a different FMS provider or previously participated in the CDCS?
Yes
No
Unsure
Start Date of Plan
-
Month
-
Day
Year
Date
End of Plan
-
Month
-
Day
Year
Date
Is the Community Support Plan (CSP) completed and/or approved?
Yes
No
Participant Information:
Please enter all of the required information for the participant (the client, person served)
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
If over 18 years of age, does RP have legal guardianship or Power of Attorney?
Yes
No
Address
Street Address / Unit / Apt
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical Assistance/PMI Number
Does the client currently utilize services with Life Fountain or utilized services in the past?
Yes
No
Does the Client have any immediate family who currently has services with Life Fountain?
Yes
No
If Applicable, Does the client have a spend down?
Yes
No
Participant Representative
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Relationship to Participant
Please Select
Parent (Biological or legally adopted)
Spouse (Legally married)
Clild (Biological or legally adopted
Other
Communication Preference? (select all that apply)
Email
Phone
Address (if different from participant)
Does PR need an interpreter? If so, what language?
Team Information
Case Manager Name
Case Manager Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Case Manager Email
example@example.com
Support Planner Name
First Name
Last Name
Support Planner Email
example@example.com
How many staff applications are needed for employees?
APPLICANT 1
Full legal name, including all middle and last names or hyphenated names (if applicable).
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County of Residence
How are you related to the Participant?
Please Select
Parent
Sibling
Spouse
Child
None of the above
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
APPLICANT 2
Full legal name, including all middle and last names or hyphenated names (if applicable).
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County of Residence
How are you related to the Participant?
Please Select
Parent
Sibling
Spouse
Child
None of the above
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: