Start Services

Start your journey with us.

Fill out the referral form below and our team will reach out within 1 to 2 business days to talk about next steps and how we can support you or your loved one.

How It Works

Complete This Form

Share the participant's information, waiver details, and referring source. All fields are submitted securely.

We'll Reach Out

A member of our team will contact you within 1 to 2 business days to discuss next steps.

Begin Your Care

Your personalized support plan begins. We work with you every step of the way.

We accept DODD waiver funding, including Individual Options, Level One, and SELF, and are committed to serving individuals of all backgrounds and abilities across Ohio.

Participant Referral

Tell us who needs support.

Referral submitted. Thank you. A member of our team will be in touch within 1 to 2 business days.

Who is this referral for?

A Child Under 18

An Adult 18 or older

Child's Information

Child's Name *

Date of Birth *

Age

Social Security Number *

Race *

Address *

Parent / Guardian Information

Parent/Guardian Name *

Phone Number *

Email Address *

Relationship to Child *

Waiver & Funding Information

County Board of Developmental Disabilities *

Waiver Type *

Medicaid / Waiver ID Number

SSA (Support and Service Administrator) Name

Referring Source

Who is making this referral? *

This form is submitted securely. For urgent needs, please call us at (216) 910-4040.