Provider Introduction Referral

This referral form allows you to share information about your experience, background and approach to support. The information you provide helps individuals and families learn more about potential providers as they explore connection opportunities through Soaring Connections.

You will also be asked to upload a current resume, provide your Medicaid provider number and list professional references. Sharing this information helps individuals and guardians make informed decisions as they explore potential connections

Provider Information

Full Name

Location

Phone

Email

Preferred Contact Method

Provider Details

Medicaid Provider Number

Your Medicaid provider number is the 8-digit number assigned to you by DHHS-DD when you enroll as a provider. This information helps confirm provider enrollment and allows individuals and families to understand your professional role within self-directed services.

Years of professional experience supporting individuals with disabilities

Years of related experience

Examples may include family support, caregiving, volunteer work or other helping roles that shaped your understanding of support and connection.

Waiver Enrollment

Which Medicaid waiver programs are you enrolled to provide services under?

AD (Aging & Disabled)

DDAD (DD Adult Day)

CDD (Comprehensive DD)

FSW (Family Support Waiver)

Start Date or Availability Start Date

Background & Experience

Describe your experience supporting individuals with disabilities or in other helping roles. Include both paid and personal experiences if they shaped your understanding of care and connection.

Include professional certifications, completed trainings, and any special skills or strengths you bring to your work as a provider.

List any college degrees or educational programs you’ve completed.

Resume & References

Provide a current resume. You may upload it here to help individuals and families learn more about your experience and qualifications.

Please provide the names and contact informatio for two references who can speak to your experience, reliability, and character as a provider. At least one reference should be professional (such as a supervisor, colleague, or case coordinator).

Getting to Know You

Share what led you to become a provider and what you enjoy most about this work. You can include your approach to support, what helps you build meaningful connections, or anything that reflects who you are as a professional.

Help individuals and families get a sense of the person behind the role (hobbies or interests you enjoy sharing with others, something fun or unique about yourself, etc).

Upload a Profile Photo (Quick Tips: one clear photo is perfect. 1. Face a window or light source, 2. Plain background works best, 3. Chest-up framing, leave a little space above your head and 4. No filters or screenshots.)

Connection Preferences

Do you have any preferences for the types of connections or supports you’re seeking? (Examples: preferred age group, activity style, daily routine fit, home environment, or specific skills you enjoy using in your work.)

Community Commitment

Providers participating in the Soaring Connections community share a commitment to respectful communication, transparency and relationship-centered support.

Additional Information, Consents and Acknowledgements

Yes, subscribe me to the Connection Highlights email list.

Submitting this form does not guarantee a referral or connection. Soaring Connections facilitates introductions based on shared values and compatibility.

I authorize Soaring Connections to confirm my provider enrollment and contact the references I have listed for the purpose of confirming professional experience and reliability.

I authorize Soaring Connections, LLC to share my referral details to help individuals and providers explore potential connections. This may include posting limited information on the Soaring Connections website, social media or community groups. Private contact information will not be shared without permission. I understand Soaring Connections cannot control how information may be used once shared publicly and that consent may be revoked at any time in writing.

Signature

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Provider Referral

Provider Introduction Referral