Self-Directed Services Referral Application

Self-Directed Services Referral Application
Application Date

MonthDayYear
Date
Individual's Name

First NameLast Name
Individual's Date of Birth

MonthDayYear
Date
Individual's Medicaid #
Ex. AB12345C
TABS ID
Primary ICD-10 Diagnosis Code
Primary Contact Phone

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
What is your preferred method of contact?
Have you attended the SDS Interest meeting hosted by OPWDD?
You answered No to attending an SDS interest meeting hosted by OPWDD.

Please reach out to your CCM or OPWDD to schedule a learning session. OPWDD requires people pursuing Self-Direction attend this learning session before becoming eligible for the Self-Direction Wavier Program.
Date you attended SDS Interest Meeting. If attended, SDS will be collecting a copy of the certificate of completion from you.

MonthDayYear
Date
Are you transferring Fiscal Intermediary services to Springbrook?
Agency Name transferring from
FI's Name transferring from

First NameLast Name
FI's Email transferring from
example@example.com
School Age?
School District Name
Support Broker
Do you prefer that brokerage be provided in person or remotely?
Agency Name
Broker's Name

First NameLast Name
Broker's Email
example@example.com
Have you identified a potential staff person to work with you?
Potential Springbrook Staff

First NameLast Name
Potential Springbrook Staff Phone

Area CodePhone Number
Potential Springbrook Staff Email
example@example.com
How did you hear about us?

Other
Date of the last CAS/CANS assessment?

MonthDayYear
Date
How did you hear about us?
Referral Choice

Other
Care Coordination Manager

First NameLast Name
Care Coordination Agency
Care Coordinator's Phone

Area CodePhone Number
Care Coordinator's Email
example@example.com
Designee/Advocate

First NameLast Name
Designee/Advocate Primary Phone

Area CodePhone Number
Designee/Advocate Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Designee/Advocate Email
example@example.com
Designee/Advocate Relationship to the Individual

Self-Directed Services Referral Application

Program Questions