Home-Based Services Inquiry Form

Please prepare the following information for when we follow up on your referral or before you call our
referral coordinator.

  • Youth’s name
  • Youth’s birthdate
  • Reason for referral
  • Please have the youths managed care insurance MMIS or social security numbers available

The guardian also has the option to call the referral coordinator at (937) 264-0084 ext. 139 or CHOICES
main line (937) 264-0084 and select make a home-based referral from our automated menu.