Referral – Lazuli Services

Referral Request Form

Referring Case Manager *

Phone number: *

Email Address *

County (CFR) and CM Agency *

Name of individual in need of service *

Date of birth *

Address *

Address Line 1

City

State

Phone number *

Multiple Choice *

PMI Number/ Medical Assistance Number *

Diagnosis and ICD10 *

Does individual have guardian *

Attach CSSP *

Click or drag a file to this area to upload.

** Please note that services will not start until individual has been approved for services by DHS.