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
PhoneEmailUSPS
YesNo
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
NoYes
Agency Name transferring from
FI's Name transferring from

First NameLast Name
FI's Email transferring from
example@example.com
NoYes
School District Name*
Independent (contracted broker)AgencySpringbrook agency broker (Springbrook employee)
In PersonRemotely
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
Community MemberOffice of People With Developmental Disabilities (OPWDD)My Care ManagerAdvertisingOther
Date of the last CAS/CANS assessment?

MonthDayYear
Date
How did you hear about us?
SelfParent/ AdvocateCare ManagerBrokerOther
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