Referral Form

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Support Coordinator/Case Manager Name*

Support Coordinator/Case Manager Cell Number

Individual's Full Name

Individual's preferred name

Individual's cell phone # (If they do not have one, put N/A)

Individual's Email (If they do not have one, put N/A)

Individual's current address

Individual's Current Living Situation

Legal Guardian(s) Name(s) (If none, put N/A)

Legal Guardian Email (If no LG type "N/A." An email address is required for DocuSign intake forms. Without a valid contact email, services may be delayed or potentially not approved, as we must have the ability to obtain signed forms through this method.)

Legal Guardian's Phone Number (If no LG, type N/A)

Legal Guardian's Address (must include city and zipcode)

Emergency Contact Name

Emergency Contact Address (must include city and zipcode)

Emergency Contact Phone Number

Authorized Representative (if applicable; if not, type N/A)

Rep Payee (if applicable; if not, type N/A)

Date of Birth (must be 18+)

Medicaid ID (If individual does not have Medicaid, they will not be eligible for services through Sunny Haven. If Medicaid is pending, type Pending and when it was last submitted.)

Tier

Current DD Waiver