To submit a referral or request for services, please do the following:
Please Note: There is a very high demand for services provided through the T4H grant. We currently have more referrals than can be served through the current grant cycle ending June 30th, 2023. The grant will renew July 1st, but we already have a 6-12 month accumulation of referrals depending on the specific services required. As such, we are putting a temporary hold on more T4H referrals until at least July 1st, except for extraordinary circumstances.
Other Options: Many Assistive Technology (AT) services can be funded by other means. The AT for Wellness program provides assessment and training, as well as some types of equipment, specific to telehealth related needs. Waivers can be used to fund many types of AT related assessments and training. See the LiveLife Therapy Solutions, Inc web site for more information on these options at – LiveLife Therapy Solutions Inc.
- Download our referral form using the button below:
- Fill it out using Adobe Reader.
- If using Microsoft Edge – On the “downloads bar” at the bottom of your browser window, click on the three dots next to the file name, then click on show in folder.
- If using Google Chrome – On the “downloads bar” at the bottom of your browser window, click on the up arrow next to the file name, then click on show in folder.
- Once you are in your downloads folder, right click on the file and select Open With -> and then select in Adobe Acrobat Reader.
- (Please do not open and fill out the form directly in your web browser. This sometimes creates issues for us when we process the document afterwards.)
- Save your work and close the referral form.
- Send the Referral Form to us securely using the following link:
If you would like a copy of our HIPAA Statement for your records, or any of our other Policy Statements, you can find them here:
Policy Statements