This form is voluntary. Please answer all the questions included on the referral. While all the items are not required to submit a referral, DVR does need this information. Not providing some of the information could delay the processing of your referral. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes].

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If you are under the age of 18 or have a court appointed guardian please select the 'New Guardian' button and answer the questions regarding your guardian.

First Name Last Name

At least one contact method is required

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Long-Term Care

Please read before responding. Long-Term Care providers are not doctors offices or primary care physicians. Long-Term Care services provide individual care on a regular and ongoing basis. This is often personal care or help with everyday activities or "activities of daily living." These include aid with bathing, dressing, grooming, eating, and movement.

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Finish Up

When you are finished filling out the information please click the submit button to send your completed referral to DVR.

If a referral is completed by someone other than the individual or their guardian you must have their consent. By checking this box you confirm receiving consent by the individual or guardian.
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Contact Info
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DVR-17445-E (R. 04/2023)