ActiveCare Home Care

Email : info@activehcare.com

Referral Form for Services and Supports

 

Referral Form for Services and Supports
  1. Referral Date
  2. Time
  3. Agency Name:
  4. Staff Person Taking Referral:
    5. PERSON MAKING THE REFERRAL:
  5. Name
  6. Phone
  7. Email
  8. Relationship to Individual in need of supports and services:
    9. INDIVIDUAL IN NEED OF SERVICES AND SUPPORTS
  9. Name
  10. Age
  11. Date of Birth
  12. Address
  13. City
  14. Zip code
  15. Phone
  16. Email
  17. If not English-speaking, preferred language
  18. Do you live alone? YESNO
  19. Safety issues (i.e. dogs)? YESNO
  20. If Yes Please describe
  21. If not a home residence, please indicate the name and type of facility where the Individual is located.
  22. Facility Name:
  23. Facility Address:
    Assisted LivingSupportive Living ProgramLong-term Care Facility (Nursing Home)HospitalHospice FacilityOther
  24. If other : Name
  26. DOES THE INDIVIDUAL HAVE A SPOUSE? YesNo
  27. IF Yes, Spouse Name
  28. Is spouse in need of services and supports? YesNo
  29. Age of spouse?
  30. Is there a friend/family caregiver or emergency contact that needs to be contacted? YesNo
  31. If yes, provide contact information (if known):
    32. DOES THE INDIVIDUAL HAVE ANY OF THE FOLLOWING?
  32. Legal Guardian YesNoUnknown
  33. Representative Payee YesNoUnknown
  34. Power of Attorney for Health YesNoUnknown
  35. Power of Attorney for Financial YesNoUnknown
  36. If yes, provide contact information (if known)
  37. Is there a friend/family caregiver or emergency contact that needs to be contacted? YesNo
  38. If yes, provide contact information (if known)
  39. Is there any other individual at this residence that needs services and supports? YesNo
  40. NOTE: If yes, complete a separate referral form if 60 or over. If under 60, refer to the proper state agency.
  41. Name of other individual (if known):
  42. Age of other individual (if known):
    43. HEALTH INFORMATION:
  43. Does the Individual have: Hearing loss? YesNoUnk
  44. Vision Issues? YesNoUnk
  45. If yes, preferred method of communication (i.e., Interpreter, TTY Relay Services or Braille Assistance):
    46. Has the Individual been told by a health care professional that they have any of the following?
  46. Alzheimer’s or any other type of dementia? YesNoUnknown
  47. Mental Health Illness? YesNoUnknown
  48. Physical Disability? YesNoUnknown
  49. Intellectual/Developmental Disability? YesNoUnknown
  50. Brain Injury (i.e., stroke, head injury, aneurysm)? YesNoUnknown
    51. ADDITIONAL INFORMATION REGARDING THE INDIVIDUAL IN NEED OF SUPPORTS AND SERVICES
  51. Reason for Referral (general concerns): Please provide any additional information regarding the Individual in
    need of supports and services that may be helpful.
  52. Does the Individual receive any supports and services now? YesNo
  53. If yes, type of supports and services are received:
  54. Is the Individual experiencing any problems with the current supports and services? YesNo
  55. Please explain
  56. Has the Individual or spouse served in the military? YesNo
  57. Is the Individual aware of the referral? YesNoUnknown
  58. Is the Individual in immediate danger? YesNoUnknown
  59. Explain:
  60. Is the Individual in need of immediate assistance? YesNo
  61. Explain:
  62. Does the Individual want someone else to be present during the home visit? YesNo
    63. What would be the best time and method to contact the Individual (if known):
  63. Time
  64. Phone:
  65. Email:

Park Ridge

1420 Renaissance Drive, Suite 211

Park Ridge, IL 60068

Chicago

6374 N Lincoln, Suite 205
Chicago, IL 60659

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