Request An Appointment Email Little Gerald Services (LGS) Referral Form Reaching out to make this a better world for our clients, their families, and our communities. Please check the box below for the service which consumer is being referred for: * Companion/Respite Peer Support Individual (Adult Only) Peer Support Group (Adult Only) SAIOP/SACOT Personal Care Services Outpatient Therapy Clinical Comprehensive/DWI Assessment Individual Supports Intensive Recovery Supports for Women B3 Respite for Children and Adults Transitional Living Young Adults in Transition Critical Time Intervention Medication Evaluation/Management Ticket to Work Program DWI Services In-home Services Community Support Team Day Treatment Date * First Name * Last Name * Address * City * State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Guardian (If Applicable) Guardian Phone * Your Phone Number * Primary Care Doctor * Primary Care Doctor's Phone Number * Reason For Referral * Referred By * Time * Proof of Insurance Statement (if applicable): I understand that due to confidentiality my Medicaid or Social Security number can not be on this form. I understand that if my services required me to verify proof of insurance, my medicaid number may be requested for eligibility for services (if applicable). * Read Unread ReCaptcha