LTSS Application Assistance Referral Form If a current Neighborhood member has been identified as potentially benefitting from Long Term Support and Services from the Department of Human Services, please complete this form. Member ID #(Required) Member's DOB(Required) MM slash DD slash YYYY Member's Name(Required) First Last Error Message Best Phone Number to Contact Member(Required)Member's Preferred Language(Required) Contact Name(Required) Contact Email(Required) Additional Comments SectionFile Upload Drop files here or Select files Max. file size: 200 MB. CAPTCHA