Refer an Individual

This Referral Form is for Regional Center Service Coordinators who would like to refer an Individual to Empowered Living Services Agency. Our team will follow up with you to discuss next steps.

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Step 1: Submit the Referral Form (please use one method, not both)

• Online: click the button below to open the form.

• By email: if you already have our PDF Referral Form on file, complete it and send it to referrals@empoweredlsa.com.

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Step 2: Send the Referral Packet
After submitting the Referral Form, send the separate, detailed Referral Packet via your Regional Center’s approved secure messaging method.