Referral

Referral

Thank you for your interest in High Fidelity Wraparound!  

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 307-459-6162 with any questions about this form and our process. 

 

Fields marked with an * are required.

 

Please fill out the following form.
Gender *
Is this youth in DFS custody? *
Is the youth currently enrolled in Medicaid? *