Contact CLSS Services

Name *

First Name

Last Name

Phone *

(###)

###

####

Are you filling out this form for yourself or for a loved one? *

Myself

A loved one

Potential Recipient's Date of Birth *

MM

DD

YYYY

Are you the authorized representative? *

Yes

No

Are you currently receiving waiver services through another provider? *

Yes

No

Have you ever received waiver services in the past? *

Yes

No

Did your or your loved one's disability occur at birth or before the age of 21? *

Yes, it occurred at birth or before the age of 21

No, it occurred after the age of 21

Do you currently have Medicaid? *

Yes

No

Have you contacted Northwest Louisiana Human Services District (NLHSC)? *

Yes

No

Are you looking for in home independent living assistance or a group home setting? *

In home independent living assistance

Group home setting

Are you the current caretaker and are you looking to become the potential recipient's paid support? *

Yes

No

How did you hear about us?

I saw an ad on Facebook

I saw an ad on Instagram

A friend / relative told me about it.

I saw a billboard.

I heard about it an other way.