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Donate
Give to Abbott House
Who You Help
Children and Families
Individuals With Developmental Disabilities
Foster Families
Your Community
Devon's Story
How You Help
Donate
Donating Goods & Services
Volunteer
Become a Foster Parent
Abbott House Golf Outing
Why Abbott House
Mission
History
Services - Children and Families
Services - Individuals with Developmental Disabilities
Leadership
Best Foster Parents Ever
Careers
Important Documents
Contact Us
CARF Accredited
Services
For Children and Families
For Adults with Developmental Disabilities
Become a Foster Parent
Health Home Services
Child and Family Treatment and Support Services (CFTSS)
Home and Community Based Services (HCBS)
News and Announcements
News
60th Anniversary Celebration Gala
Services
HCBS Request for Services Form
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Child's Name
First Name *
Middle
Last Name *
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Day
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Date of Birth (Required)
Medicaid/CIN # (Required)
Personal Making Referral
First Name *
Last Name *
Contact Number (Required)
Referring Agency Name
Contact Number
Care Coordinator Name:
First Name
Last Name
Contact Number
Case Planner Name
First Name
Last Name
Contact Number
Manage Care Company Name (Required)
Contact Number: (Required)
Member ID# (Required)
Basic Demographics
Child's Current Address
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
Gender
Male
Female
Not Known
School Name: (Required)
School Address
Country
Address Line 1 *
City *
State/Province *
Postal Code *
If other please specify below
School Contact Name/Title
First Name
Middle
Last Name
School Contact Number: (Required)
Caregiver Information:
Name
First Name *
Last Name *
Primary Contact Number: (Required)
Second Contact Number:
Address
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
Presenting Behaviors (Please Explain) (Required)
HCBS Service Request
*Please Note
Child must be Medicaid-eligible
Access is through Children's Health Home (HH) or State-Designated Independent Entity C-YES
HH Care Manager or C-YES will complete HCBS Level of Care Eligibility Determination
Community Habilitation
Caregiver/Family Supports and Services
Respite
Prevocational Services
Supported Employment
Community Self-Advocacy Training and Supports
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