Uplifting Our People LLC — Request Services - For adults ages 18 and older. Complete this form to request services. Eligibility and availability will be reviewed before services begin.

This form is not monitored for emergencies. For immediate danger or a medical emergency, call 911.

Client Information

First name

Last name

Email address

Phone number

I'm already a client

Date of Birth

County of Residence

Contact preference (optional)

Share the best time to contact you or any communication needs.

Insurance Plan / Company

Enter your insurance plan name, or “None” if uninsured.

Member / Medicaid ID

Enter your ID if available.

May we leave a voicemail at the phone number provided?

Yes No

Referring provider / agency (optional)

Referring provider phone number (optional)

Your information will be encrypted.