Independent Support Broker Interest Form

Date of Notification

Name (As it appears on your Broker Authorization)

NYS Broker Authorization Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

(This email address will also be used as your system login.)

Areas You Serve

Will you be providing Support Brokerage services to a person who is already receiving Self-Directed Services (SDS) through Springbrook?

Will you or a Care Manager be referring a person who is new to Springbrook Community Connections?

Have you used any of the following applications?

Original Broker Authorization Letter, or most recent annual authorization letter.

If needed, you can submit a referral using the following link:

https://springbrook.jotform.com/250406043976962

To learn more about our Self-Directed Services, please visit our website:

https://springbrookconnections.org/my-independence/

Next Steps

Once you submit this form, a member of the Self-Directed Services (SDS) team will contact you to discuss the next steps, including the Independent Support Broker Agreement and any questions you may have.

Your contact information will also be forwarded to the Human Resources Department. A Human Resources representative will contact you to schedule fingerprinting as part of the onboarding process.