A Brighter Day Referral
We welcome individuals, families, and community partners to complete this referral form. Whether you’re seeking support for yourself, referring someone you know, or opening your home as a companion home for adults with intellectual and developmental disabilities (IDD), your submission helps us connect you with the right care and resources.
Your Full Name
*
First Name
Last Name
Your Contact Information
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Which best describes you?
*
I would like to make a referral
I would like to become an AFL provider
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Thank you. Let’s start with a few details about the individual you’d like to refer.
Full Name of the Person Needing Support
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Wonderful! Let’s start with a few questions about you so we can learn how to support your goals.
Do they have an intellectual or developmental disability?
*
Yes
No
Not Sure
That’s great. I’ll ask a few questions to help us connect you with our foster care and IDD support team.
Are they currently receiving any support services?
Yes
No
Not Sure
What kind of support are you looking for?
*
Day Program
Residential Care
Foster Care
Other
How would you prefer us to contact you?
*
Phone
Email
Text Message
Do you consent to sharing this information with our team to help provide support?
*
Yes
No
Do you know if the person has Medicaid, private insurance, or other funding for services?
*
Yes
No
Unsure
Please provide the insurance or funding provider name.
Medicaid, Blue Cross NC, UnitedHealthcare, Innovations Waiver
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Host Home or AFL Provider Information
This section is for families or individuals interested in providing care or housing for someone with an intellectual or developmental disability (IDD).
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you provided care or fostered before?
*
Yes – I have previous experience.
No – I’m new to this process.
Currently licensed but haven’t provided care yet.
Other
If yes, please describe your experience or the type of individuals you’ve supported.
If yes, please describe your experience or the type of individuals you’ve supported.
Please explain.
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Submit
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