Begin Intake — Core Support Connection

Personal Information

Full Legal Name

Preferred Name

Date of Birth

Phone Number

Email Address

Mailing Address

County

Emergency Contact

Contact Name

Contact Phone

Relationship

Tell Us About Your Situation

What's going on right now? What prompted you to reach out?

What are your goals? What does a good outcome look like for you?

Service Rate Selection

Select the rate tier that applies to your situation. All tiers receive the same quality of person-directed care.

Standard Rate $35 – $40 / hour

Full-rate, one-on-one person-directed services. Personalized support tailored to your goals, schedule, and service plan.

Income-Based Rate $20 – $25 / hour

For clients receiving SNAP/EBT, SSI/SSDI, or Medicaid. Proof of eligibility required. Same quality of care, same services — at a rate that works for your family.

Group Outings — Add-On $10 – $20 / person

Community-based group activities, social outings, workshops, and shared skill-building sessions. Available to any enrolled client receiving Standard or Income-Based services.

Preferred Payment Method

Core Support Connection is actively preparing for Medicaid enrollment through MyCare Ohio. Expanded payment options expected in 2026.

Referral & Preferences

How did you hear about Core Support Connection?

Preferred Contact Method

Email Phone Text No Preference

Your information is protected under our Privacy Policy. We will never share your personal details without your written consent.

Intake Form Submitted Successfully

Thank you for reaching out. Our team will review your information and contact you within 1–2 business days to schedule your welcome call.

Begin Your Intake