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Enroll with PICS | Make a Referral
Participant's first and last name (person receiving service)
First and last name
Service type:
Community First Services and Supports (CFSS)
Consumer Support Grant (CSG).
Consumer Directed Community Supports (CDCS).
Individualized Home Supports without training (Traditional) - This service includes respite, homemaker, night supervision, chore, caregiver living expense.
Individual Private Pay.
Unsure.
What is the expected start date of the services?
Start date
Who is completing this form?
Individual who will receive services.
Family member or friends.
County Representative.
Consultation Services.
Case Manager.
Care Coordinator.
CDCS Support Planner.
Other.
Your first and last name
Your phone number
Your email
Will you manage the Participant's services?
Yes
No
Who will be the Participant's Representative?
What is their relationship to the Participant?
Representative's phone number
Representative's email
Preferred method of contact:
Phone
Email
Does the Representative need an interpreter?
Yes
No
Do you need an interpreter?
Yes
No
Please list their primary or preferred language
Please list your primary or preferred language
How did you hear about PICS?
Case Manager/Care Coordinator/CDCS Support Planner/Consultation Services.
Newspaper/online ad.
Internet search.
Friend or family member.
Conference or event.
PICS or LSS employee.
Department of Human Services' (DHS) Financial Management Service (FMS) website.
Other.
Any comments or questions you have about starting services with PICS?
Leave this field blank
