Referral application

Tell us how to reach you and which services you are looking for. Our team will contact you to discuss availability and next steps. Fields marked * are required.

How to send your referral: Complete this form and select “Submit referral request.” You will receive a confirmation on this page after your request is saved. Our team will review it and contact you.

Your contact information

Your full name *

I am a… *

Phone *

Email *

Organization, if applicable

Preferred contact method

Requested services

County where services are needed *

Primary service requested *

Waiver or funding program

Preferred start date

Preferred days, times, or hours of support

What would you like our team to help with?

Review your referral request

This initial request helps us arrange a conversation. Please do not include a participant’s date of birth, Medicaid or Social Security number, diagnosis, medical records, or ISP. Our team can explain how to share any required documents securely.

I agree that Opulent Residential Services LLC may contact me about this referral request. *

When you submit, your contact information and request are saved for review by Opulent’s website owner. Downloading or printing does not submit the form. Please provide only the information needed to arrange a conversation.

Need help with a referral? Call (412) 721-2789.