Request Services

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Full Name if Individual Seeking Services(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Gender or Preferred Pronouns

She/Her

He/Him

They/Them

If prefer to self-describe, please state

Primary Language(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

I am the individual seeking services(Required)

If no – Please state full Name, relationship to the individual, phone number and email address:

If you are not the individual seeking service, are you authorized to share this information? If no, we may need the individual or legal guardian to provide consent before moving forward. We will contact the person listed here first for next steps.(Required)

Service Coordinator Name

Optional.

Agency

Optional.

Coordinator Phone

Optional.

Coordinator Email

Optional.

Do you already have a person-centered plan (PCP) in place?

Yes

Please upload PCP here

Max. file size: 16 MB.

Services Requested(Required)

Community Living Group Home

Personal Support Services

Community Development Services

OHCDS Transportation Services

Nursing Support Services

Employment Services

Supported Living

Daily Respite in CLGH

Respite Care Services

Other

Needs and Preferences (For example: learn daily living skills, build friendships, find a job…)

What type of support is most important right now? (For example, help at home, structured day activities, nursing care, transportation)

Preferred living arrangements (if applicable)(Required)

Preferred Community/County for Service

Best time to contact you

Morning

Afternoon

Evening

Weekend

Primary Support Needs (List diagnosis or disability if applicable, and areas where support is needed most)

Health Considerations

Mobility

Uses wheelchair

Uses walker

Other

If other, please describe

Communication

Verbal

Non verbal

Uses device

Other

If other, please describe

Current services already in place (if any) For example, current provider, hours per week, school program, day program

Upload any care plans or supporting documents

Max. file size: 16 MB.

I understand this form is an initial request for services and does not guarantee placement. A member of the Helpful Hearts Health Services team will follow up to discuss next steps.

I Agree

Name

First Last

Date

MM slash DD slash YYYY

Main Office

Request Services

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