Provider Match Inquiry

Funding Program*

Please enter the program which applies to this referral.

Rising Phoenix - CCS

Glowing Embers - CLTS

Glowing Embers - County Direct Payment - Transition to CCS

Glowing Embers - County Direct Payment - Safe Landing

CCS Service(s) Desired*

Please enter the CCS service desired. If there is more than one service desired, please select all that apply.

CLTS Service Desired*

Please enter the CLTS service desired. If there is more than one service desired, please select all that apply.

Communication Assistance for Community Inclusion

Community Integration Services

Daily Living Skills Training

Empowerment and Self-Determination Supports

Family/Unpaid Caregiver Supports and Services

Health and Wellness

Respite Care

County Direct Service Needed*

Please select from the options or describe the desired service. You must hit "Enter" after entering the information so your answer remains in the box.

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Safe Landing Service Needed*

Please select from the options provided or describe the desired service. You must hit "Enter" after entering the information so your answer remains in the box.

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Referral Method*

If you are a Service Facilitator or Service Coordinator and you are completing this form, please select "Direct Entry by SF / SC". If you reached out via email to one of the listed email addresses or directly to a service provider, please select that option.

Service Facilitator*

Please enter the Service Facilitator's name or type in one if it isn't listed. If your name isn't listed, please and hit "Enter" after typing your name so your answer remains in the box.

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Service Coordinator*

Please enter the Service Coordinator's name or type in one if it isn't listed. If your name isn't listed, please and hit "Enter" after typing your name so your answer remains in the box.

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Email Address for the Service Facilitator or Service Coordinator

Please enter your email address and hit "Enter" afterwards to save your answer.

Phone Number for the Service Facilitator or Service Coordinator

Please enter your phone number(s) and hit "Enter" afterwards to save your answer.

Recipient's Age*

Please enter the recipient's age or approximate age.

Client's Location*

Please enter the recipient's hometown or area for assistance in matching with an appropriate provider. You must hit "Enter" after entering the information so your answer remains in the box.

Preferred Language*

Please select the recipient's preferred language.

English

Spanish

American Sign Language (ASL)

Other

Preference for Gender of Provider*

Please enter the preferred gender for the provider's gender or select "Either" if there is no preference.

Male

Female

Either

Willing to consider another gender provider*

If you chose a specific gender, would the service recipient consider an alternative option. (ie. If the service recipient requested a male provider, would the recipient consider a female provider and vice versa.)

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Specific Requests Regarding Provider*

If there are specific concerns that must be adhered to in matching a recipient to a provider, please select it here. You can select more than one. If none, please select "N/A". You can type in your own response, but you need to hit "Enter" after typing it so the answer remains in the box.

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Frequency and Length of Visits Requested*

Please enter the frequency and length of visits requested.

For example, are you looking for a provider once a week for a 2-hour session? Does the client need a provider three days a week for one-hour visits?

Client is UNABLE to meet at the following days/times:*

Please enter times that the client is UNABLE to have a provider visit. For example, the client may have a work or school schedule, other provider appointments/therapies, etc.

If there aren't blocked out times, please enter "N/A".

Diagnoses*

Please select from the listed diagnoses or type in any additional ones not listed. You may select more than one. If typing in something, you need to hit "Enter" after typing so the information remains in the box.

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Recipient's Background*

Please enter any pertinent background information that would be helpful in matching the recipient with a service provider. This could be family functioning, development, educational history, etc.

Recipient Interests*

Please enter any interests that the recipient has that may assist with matching them to the service provider that would be the best fit for them. Please type in any that aren't listed, if applicable. If typing in something, you need to hit "Enter" after typing it in order for the information to remain in the box.

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Recipient's Goals*

Please list the goals or objectives that the recipient wishes to work towards.

Possible CCS Provider(s)*

If there are any service providers that you feel may be a good fit for the recipient, please select them here. If there aren't any specific ones you are interested in, please select "Any". You may select more than one potential provider.

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