Request Services or Make a Referral

Complete the short form below and our team will follow up to discuss next steps.

Takes less than 2 minutes to complete.

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I'm a CCS or professional making a referral

Use our faster Professional Referral form instead — built for professionals connecting a participant with HAVE Support.

Request services for myself or someone I support

Your Information

Tell us who is submitting this inquiry.

First Name

Last Name

Relationship to Participant

Email Address

Phone Number

Organization or Agency(optional)

Preferred Contact (optional)

PhoneEmailText

Person Seeking Services

Tell us about the person who would receive services.

Participant First Name

Participant Last Name

County

Date of Birth(optional)

Participant Phone(optional)

Participant Email(optional)

Program or Service Model

Select the program or service model you are inquiring about.

Program or Service Model

Services Requested

Service(s) Requested

Select all that apply. You may choose from multiple categories.

Additional Service Information

All fields in this section are optional.

Is the service currently authorized?(optional)

Requested Start Date(optional)

Brief Description of Support Needed(optional)

0/1000

Urgency

How soon are services needed?

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Our team typically responds within one business day.

Request Services or Make a Referral

Your Information

Person Seeking Services

Program or Service Model

Services Requested

Additional Service Information

Urgency

Authorization and Submission