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

Park Ridge

1420 Renaissance Drive, Suite 211

Park Ridge, IL 60068

Chicago

6374 N Lincoln, Suite 205
Chicago, IL 60659

Office Hours

Mon – Fri:
9:00am – 5:00 pm