Family Support Services Referral v2

Family Support Services Referral
Before proceeding with the referral process, please ensure that you download and complete the necessary documents so they can be attached to the online referral form. For your convenience, the Application and Service Agreement forms are available for download below.

If you have any questions or need assistance, please contact us at BridgeHealthFamilySupport@lmcs.org.
To apply for Family Support Services, please complete the referral form online; print and complete the Application and Agreement, and include at least two (2) of the following supporting documents of diagnosis (the more the better), as well as proof of citizenship:
- Family Supports Referral Form
- Family Supports Application
- Family Supports Agreement
- Supporting Documents of DiagnosisPsychological Evaluation (most recent)
- School Individualized Education Plan (Finalized, not a Draft)
- Functional Limitations Evaluation from Occupational or Physical Therapist
- Medical Verification
- Social Security Disability Benefits Award Letter
- Other: Related Diagnosis Documentation
Copies of the following documents to prove citizenship are a birth certificate, adoption/guardianship papers, social security card, etc.
Once completed, email the Family Support Services Application AND Agreement with supporting documentation to bridgehealthfamilysupport@lmcs.org or mail the documents to:

Bridge Health
ATTN: Family Supports
1427 Lee Clarkson Road
Chickamauga, GA 30707

For more information:

Please contact our Family Supports Team by email: bridgehealthfamilysupport@lmcs.org
Family Support Services Application
Family Support Services Agreement
Date of Application: *

MonthDayYear
Date
Individual Name:*

First NameLast Name
Social Security Number: *
Gender:*

MaleFemale
Date of Birth:*

MonthDayYear
Date
Age:*
Race (optional):*

American Indian or Alaskan NativeAfrican AmericanMulti-Racial/Ethnic GroupAsian or Pacific IslanderCaucasian/AngloOther
Ethnicity (optional):*

Not HispanicHispanic or Latino
Insurance Information
Private:
Public (Medicaid) #:
Family Member/Guardian Name:

First NameLast Name
Relationship to Individual:

Legal GuardianParent of Minor ChildGuardian of an Adult IndividualOther
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence*
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Section II: Diagnostic Information
Developmental Disability Diagnosis: Check which of the following disability categories is most relevant to the identified individual:*

Autism Spectrum DisorderIntellectual DisabilityCerebral PalsyMuscular DystrophyNeurological Impairment (Prior to age 22)Developmental Delay (0-8)Traumatic Brain Injury (Prior to age 22)Other
Age at Time of Diagnosis:*
Should be Empty:

Family Support Services Referral

Insurance Information

Section II: Diagnostic Information