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Enroll with PICS | Make a Referral

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Enroll with PICS | Make a Referral

Please complete the form below to get more information about PICS services or to refer yourself, a loved one, or someone you support to PICS. Our enrollment team will contact you as soon as possible!

If you prefer to speak with a PICS representative, please call 651.967.5060 or 888.874.7427. We look forward to hearing from you!

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

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

Does the Representative need an interpreter?

Yes

Do you need an interpreter?

Yes

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

Partners in Community Supports is a service of Lutheran Social Service of Minnesota.

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