Please complete all required fields in the form below. Most importantly, we need accurate contact information (legal guardian’s phone number, email address) and the youth’s Medicaid/SSN so that our staff can follow-up with the referral and begin the enrollment process. Upon successful completion the youth/family will receive a letter with more information and how to contact us. Please call 1-855-883-8740 with any questions about this form and our process.
