Request for Services - Goodwill of the Heartland

Use this form to make a formal referral for services

This form is required when a formal referral is needed. A formal referral is needed when our services will be purchased by one of our funders (IVRS, Region, MCO, IME, school).

People without funding should use the Get Started With Goodwill online form, visit one of our Helms Career Centers or sign up for an account with our Virtual Career Center.

If you have questions or need assistance, please use our contact form.

Eligibility Requirements

The person you are referring must:

★ be 16 years of age or older (exceptions made on a case-by-case basis by the Vice President of Mission Services)

★ have documentation of a disability or disadvantaging condition, as required by funding source

★ not be harmful to self or others

★ capable of or able to arrange transportation for in-person services

★ capable of or able to arrange physical care during services

★ participate at full potential

★ not be on the sex offender registry (Day Habilitation program only)

★ be able to function in a community setting without 24-hour supervision (SCL program only)

★ meet the VA/DOL definition of homeless (Veterans program only)

In addition, Goodwill of the Heartland must have availability of services and supports that match the individual's preferences, strengths and needs.

Request for Services Form

Your Information

Please provide the information of the person making this referral for services. We will use this information if we have additional questions.

This field is hidden when viewing the form

Date & Time

Referring Person's Name(Required)

First Last

Referring Person's Title/Relationship(Required)

Referring Person's Phone Number(Required)

Referring Person's Email Address(Required)

Person You Are Referring

Please be sure to answer all required questions. The form will not submit if you have skipped required information.

Referral's Name(Required)

First Middle Initial Last

Referral's Preferred Name

Referral's Pronouns

Referral's Birthdate(Required)

MM slash DD slash YYYY

Referral's Full Social Security Number(Required)

Please enter only numbers; no dashes

Referral's Current Address(Required)

Street Address Address Line 2 City State ZIP Code

Referral's Current Phone Number

Referral's Primary Diagnosis(Required)

Diagnosis Code (ICD-10)

Interpreter Required?(Required)

Yes

Is your agency arranging/providing the interpreter?

Yes

Current Guardian?(Required)

Yes

Current Guardian's Name

First Last

Current Guardian's Phone

Current Guardian's Email Address

Desired Program

Not all programs are available at all locations. Once you choose your preferred region, additional options will appear.

Select Goodwill Region(Required)

Iowa City Goodwill Programs:

Select all that apply

Day Habilitation

Supported Community Living

Employment & Training

Other

Cedar Rapids Goodwill Programs:

Select all that apply

Day Habilitation

Supported Community Living

Employment & Training

Other

Davenport Goodwill Programs:

Select all that apply

Day Habilitation

Employment & Training

Other

Clinton Goodwill Programs:

Select all that apply

Employment & Training

Other

Burlington Goodwill Programs:

Select all that apply

Employment & Training

Other

Muscatine Goodwill Programs:

Select all that apply

Employment & Training

Other

Funding Type

Not all forms of funding are available for all programs.

What funding is available to the referral?(Required)

Medicaid Waiver

Region Funding

Iowa Vocational Rehabilitation Services

Other

What type of Medicaid Waiver?

Habilitation

Supplemental Information

Additional Participants(Required)

Does another person need to receive an invitation to the introductory meeting?

Yes

Additional Participant Name

First Last

Additional Participant's Title/Relationship

Additional Participant's Phone Number

Additional Participant's Email Address

Something more to share?

Please use this space to provide any additional information or considerations.

Optional File Upload

While the Request for Services process can move forward without additional documentation at this time, we will eventually require a documentation of diagnosis, most recent social history guardianship paperwork (if applicable) and the most recent assessment (if applicable). If those are available now they can be uploaded.

Accepted file types: docx, pdf, Max. file size: 256 MB.