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These services are provided in the home and community based supports to assist children and/or adolescents to resolve behavioral problems and function more successfully.

BHIS Referral Form

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*Additional Resources*

Home and Community-Based Services

Referral Application

Application Date: * required

Referral Name, Phone, Email:

Service

Day Habilitation

Desired Location

Additional Information

Check all that apply

ID Waiver

Habilitation

Employment

Check all that apply

ID Waiver

BI Waiver

IVHRS

Habilitation

Homes

Check all that apply

BI Waiver

ID Tier 1

ID Tier 2

ID Tier 3

ID Tier 4

ID Tier 5

ID Tier 6

Hab UC

Hab UD

Hab U8

Hab U9

Hourly Community Supports

Check all that apply

ID SCL

BI SCL

Habilitation

Ind. Respite

Group Respite

CDAC

RCF

Keosauqua Location Only

APPLICANT INFORMATION:

Applicant Name:

Address:

Primary Phone #:

Birth Sex *

Male

Female

Medicaid ID#

Date of Birth: * required

Gender Identity *

Male

Female

Other

Insurance Provider or MCO:

Age:

Applicant Marital Status *

Married

Single

Divorced

Primary Funder

Does the person get SSI or SSDI? *

Yes

No

Application in process

If yes, Amount Received per month

Does the person have a legal guardian? *

Yes

No

Does the person have a case manager or care coordinator? *

Yes

No

Is the person on the Sexual Offender Registry? *

Yes

No

Is the person under a mental health committal? *

Yes

No

Is the person on probation? *

Yes

No

Name & phone number of legal guardian:

Name & phone number of Case Manager

Reason for Referral:

Other improtant information to know about this referral:

Thank you for your interest in First Resources Corp!

Please call 641-682-8114 or email referral@firstresources.us for any questions

In order to speed up the application process, please send or upload a copy of the following information:

Social History

Current Individual Plan