A Few Quick Questions Before We Talk...

How can I reach you?

First Name *

Last Name *

Phone *

Email *

Tell me a bit about what's going on...

Which best describes your role? *

My adult child (age 18+) has disabilities

My adult sibling has disabilities

My child (age 0-18) has disabilities

Professional (Case Manager, Attorney, Behavior Specialist, etc.)

Other

I need help with: *

Getting approved for Medicaid or waiver services

Figuring out the next steps for the future

Finding and hiring caregivers

Building a team of caregivers

Managing the people who already help us

Participant-Directed Services (PDS)

Thinking through creative solutions

Honestly, I'm not sure... I just know I need help

Something else

What do you hope happens after we talk? *

I want to feel less overwhelmed and know what to do next

I’m hoping to get answers to a few big questions

I need help figuring out what’s even possible

I want to understand the best options for my situation

Honestly, I’m not even sure what I need—I just know I need help

What’s going on that made you reach out? *

(Write anything you’d like to share—it helps me understand your situation.

How are you feeling about making changes or trying something new? *

I’m ready to take action and try something new

I want to make changes but need help figuring it out

I feel stuck and don’t know what else to do

I’d rather stick with what I know

I’m just looking around for now

Something else

How soon do you need help? *Note: Samantha is not an emergency services provider. If you have an emergency dial 911 or contact your local crisis team at: https://dbhdid.ky.gov/documents/ddid/csb/crisis.pdf

What do you hope life looks like for your loved one in the future? *

Anything you want to share is helpful—big goals, small wishes, anything.

When it comes to getting support, what feels true for you? *

I’ve been trying to manage through the system, but I need more support—and I’m open to paying for help that actually works

I know I need more help than I’m getting but I'm not sure if I'm ready to pay for support

I’m only able to move forward with services that are fully covered by Medicaid free

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