DDS Referral Form

Empowering Lives, One Client at a Time.

Thank you for considering A1 Care for your client’s needs. Please complete the form below to help us understand how we can best support your client. Our team will review the referral and contact you promptly for next steps.

Referring Coordinator Information

Individual's Details

Care Needs and Preferences

By submitting this form, I confirm that I have obtained the client’s or their legal guardian’s consent to share their information with A1 Care for the purpose of arranging services.