Enroll with PICS

Please complete this form to get more information or to set up an appointment with a PICS enrollment coordinator. We will contact you to start the enrollment process within 48 hours.

Individual Who Will Manage Services

First Name

Last Name

Relationship to individual receiving services

Phone

Email (if any)

Individual Who Will Receive Services

First Name

Last Name

Program Information

The type of program you receive

Consumer Support Grant (CSG)

Consumer Directed Community Supports (CDCS)

Individualized Home Supports without training (Traditional)

Individual Private Pay

How did you hear about PICS?

Comments or questions