Intake Referral Form

Intake Referral Form

Please fill out this form if you would like to make a referral for services for yourself, a family member/friend or other connection, or if you have a general question about services. A member of our intake team will be in contact with you. We are currently experiencing a high volume of contacts to our intake line and are working as quickly as possible to respond. We appreciate your patience. Please only complete one form of contact to prevent further delay in response time.

If you have an urgent health and safety need requiring immediate support, please contact our Case Management Care Team at 303.858.2222 or CMCareTeam@dpcolo.org.

Thank you again for your patience and we look forward to supporting you!

Primary Contact Information

Primary Contact First Name*

Please enter the primary contact's first name

Primary Contact Last Name*

Please enter the primary contact's last name

Primary Contact Email Address

Please enter the primary contact's email address

Primary Contact Phone Number*

Please enter the primary contact's phone number

Phone

Individual's County of Residence*

Select

Referral Source*

How do you/your organization work with the individual being referred?

Select

Reason for Referral*

Please select the option that best describes the reason for your referral.

Select or enter value

Preferred Language*

If your preferred language is not listed, please type it into the space below.

Select or enter value

Other Language*

Do you require an interpreter?*

Yes

Do you have a preferred interpreter? If so, please provide their name and contact information here.*

Relation of Primary Contact to Individual/Applicant*

Select or enter value

Release of Information

So that we can serve you quickly and efficiently, please complete a Release of Information (Autorización de divulgación e intercambio de información) and attach it at the bottom of this form.

Individual/Applicant Information

Individual's First Name*

Please enter the first name of the individual seeking services

Individual's Last Name*

Please enter the last name of the individual seeking services

Date of Birth*

Please enter the birth date of the individual seeking services

Medicaid ID

If the individual seeking services has a Medicaid ID, please enter it here.

If the individual does not have a Medicaid ID, have they applied for Medicaid?

Select or enter value

Developmental Pathways only serves individuals residing in Douglas, Arapahoe, and Elbert counties. If the individual lives in another county, please refer to this list to determine the appropriate Case Management Agency (CMA) for the county of residence

Additional Referral Information

DHS County

Select

Other DHS County

Please indicate the childrens' waiver(s)/program(s) in which you are interested:*

Select all that apply

Select

Please indicate the adult waiver(s) in which you are interested:*

Select all that apply

Select

Please follow the links below to review the selected waiver(s)' requirements and additional information:

Supported Living Services (SLS) waiver- https://hcpf.colorado.gov/supported-living-services-waiver-sls

Developmental Disabilities (DD) waiver- https://hcpf.colorado.gov/developmental-disabilities-waiver-dd

Elderly, Blind and Disabled (EBD) waiver- https://hcpf.colorado.gov/elderly-blind-disabled-waiver-ebd

Community Mental Health Services (CMHS) waiver- https://hcpf.colorado.gov/community-mental-health-supports-waiver-cmhs

Brain Injury (BI) waiver- https://hcpf.colorado.gov/brain-injury-waiver-bi

Complimentary and Integrative Health (CIH) waiver - https://hcpf.colorado.gov/complementary-integrative-health-waiver-cih

Children’s Home and Community Based Services (CHCBS) waiver- https://hcpf.colorado.gov/childrens-home-and-community-based-services-waiver-chcbs

Children’s Life Limiting Illness (CLLI) waiver- https://hcpf.colorado.gov/children-life-limiting-illness-waiver-clli

Childrens Extensive Supports (CES) wavier- https://hcpf.colorado.gov/childrens-extensive-support-waiver-ces

Children’s Habilitation Residential Program (CHRP) waiver- https://hcpf.colorado.gov/childrens-habilitation-residential-program-waiver-chrp

Family Support Services Program (FSSP) - https://www.dpcolo.org/programs-services/long-term-care-case-management/family-support-program/

Are you interested in services and supports for individuals with intellectual and developmental disabilities?

Please check box if yes.

What connection do you/have you had with Developmental Pathways?*

Select or enter value

Which Case Management Agency have you worked with previously?*

Select or enter value

Please enter the name of your previous case management agency.

Please describe the reason for your referral.*

What information do you need, or what questions do you have?*

Is there anything else you'd like us to know?

Required Forms: For Intellectual and Developmental Disability Supports Only

In order to complete a disability determination, we require a completed Release of Information (Autorización de divulgación e intercambio de información) and a completed Request for Determination of Developmental Disability application (Solicitud de determinación de discapacidad del desarrollo). Please use the links to download and complete these forms; you can upload them to this form, or email them to us at a later point. We will not be able to proceed until these forms are completed and received.

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