ActiveCare Home Care

Referral Form for Services and Supports

 

    Referral Form for Services and Supports
    1. PERSON MAKING THE REFERRAL:
    2. INDIVIDUAL IN NEED OF SERVICES AND SUPPORTS
    3. YESNO
    4. YESNO
    5. If not a home residence, please indicate the name and type of facility where the Individual is located.
    6. Facility Address:
      Assisted LivingSupportive Living ProgramLong-term Care Facility (Nursing Home)HospitalHospice FacilityOther
    7. YesNo
    8. YesNo
    9. YesNo
    10. DOES THE INDIVIDUAL HAVE ANY OF THE FOLLOWING?
    11. YesNoUnknown
    12. YesNoUnknown
    13. YesNoUnknown
    14. YesNoUnknown
    15. YesNo
    16. YesNo
    17. NOTE: If yes, complete a separate referral form if 60 or over. If under 60, refer to the proper state agency.
    18. HEALTH INFORMATION:
    19. YesNoUnk
    20. YesNoUnk
    21. Has the Individual been told by a health care professional that they have any of the following?
    22. YesNoUnknown
    23. YesNoUnknown
    24. YesNoUnknown
    25. YesNoUnknown
    26. YesNoUnknown
    27. ADDITIONAL INFORMATION REGARDING THE INDIVIDUAL IN NEED OF SUPPORTS AND SERVICES
    28. Reason for Referral (general concerns): Please provide any additional information regarding the Individual in
      need of supports and services that may be helpful.
    29. YesNo
    30. YesNo
    31. YesNo
    32. YesNoUnknown
    33. YesNoUnknown
    34. YesNo
    35. YesNo
    36. What would be the best time and method to contact the Individual (if known):

    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