Client Referral & Intake Form

Complete the form below to submit a secure referral for client placement, housing, or treatment services. Submissions automatically notify the intake team.

Scan to email a referral

Referral Source Information

Details of the individual or agency submitting this referral.

Referring Agency / Organization *

Referrer Full Name *

Referrer Phone Number

Referrer Email Address

Date of Submission

Client Demographics

Personal details of the client being referred.

Client Full Name (First, Middle, Last) *

Date of Birth *

Primary Phone Number

Email Address

Current Address / Location

Placement & Service Details

Service type, urgency, and care notes.

Type of Service Requested *

Living / Housing Accommodation Treatment Support Services Combined Living & Treatment Program Other

Urgency Level *

Immediate / Emergency Placement (Within 24-48 hours) Standard Intake (Within 3-7 business days)

Special Accommodations or Care Notes

Insurance & Funding Information

Primary insurance policy, and Medicaid/MCO details.

Primary Insurance Provider

Insurance Policy ID

MCO Name (if applicable)

Required Document Uploads

Attached files will be automatically sent via PHP email.

1. Government Identification

2. Medicaid / Insurance Card

Acknowledgement & Submission

I confirm the information provided is accurate and consent to Easy Living Concierge Group reviewing this referral.

Emails will be sent to ez123living@gmail.com and elizeleseignious1@gmail.com

Intake Referral Dashboard

Track and manage submitted client referrals.

Referral Dispatched!

The submission and attached files were sent via PHP mail processor to:

• ez123living@gmail.com

• elizeleseignious1@gmail.com