Apply for Services

Whether you're applying through Kentucky Medicaid waiver funding or as a self-pay client, our simple online application will connect you with the right team.

App Type

Basic Info

Emergency

Services

Review

Step 1 of 5

Choose Your Application Type

Select the option that best describes how you'll be funding services. Not sure? Learn about Kentucky waivers →

Waiver-Based Application

For individuals enrolled in, or eligible for, a Kentucky Medicaid Waiver program. No out-of-pocket costs.

MPW SCL CHILD Waiver iRise ABI

Self-Pay Application

For individuals who wish to receive services without Medicaid waiver funding. Flexible billing options available.

Private Pay Insurance Flexible Billing

Step 2 of 5

Applicant Information

Please provide the basic information for the person applying for services.

First Name *

Please enter a first name.

Last Name *

Please enter a last name.

Date of Birth *

Please enter a date of birth.

Phone Number *

Please enter a phone number.

Email Address *

Please enter a valid email address.

Home Address

Street Address *

Please enter a street address.

City *

Please enter a city.

State

Zip Code *

Please enter a zip code.

County

Step 3 of 5

Emergency Contact

Please provide a contact person in case we need to reach someone on your behalf.

Contact Name *

Please enter an emergency contact name.

Relationship *

Please select a relationship.

Phone Number *

Please enter a phone number.

Email Address

Optional

Current Case Manager (if applicable)

Do you currently have a case manager?

Step 4 of 5

About the Applicant

Tell us a bit about the person's needs so we can connect them with the right program.

Primary Diagnosis or Disability *

Please enter a primary diagnosis or disability.

Current Waiver Type (if applicable)

Services Requested

Select all that apply.

Case Management

Care coordination and goal planning

Community Living Supports

Building social and daily skills in the community

Behavioral Supports

In-home behavioral therapy and counseling

Supported Employment

One-on-one coaching to find and keep a job

Respite Care

Scheduled relief for parents and primary caregivers

Personal Assistance

Help with daily living activities

Additional Notes

Step 5 of 5

Review & Submit

Please review your information below before submitting. You can go back to edit any section.

Application Type

Edit →

Applicant Information Edit →

Emergency Contact Edit →

Services & Needs Edit →

Application Submitted!

Thank you for applying to Community Inclusion KY. Our team will review your application and reach out within 3–5 business days to schedule your initial screening.

If you have any questions in the meantime, email us at info@communityinclusionky.com or call 606-770-3300.

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