Referral Date

Time

Agency Name:

Staff Person Taking Referral:

Name

Phone

Email

Relationship to Individual in need of supports and services:

Name

Age

Date of Birth

Address

City

Zip code

Phone

Email

If not English-speaking, preferred language

Do you live alone? YESNO

Safety issues (i.e. dogs)? YESNO

If Yes Please describe

If not a home residence, please indicate the name and type of facility where the Individual is located.

Facility Name:

Facility Address:
Assisted LivingSupportive Living ProgramLong-term Care Facility (Nursing Home)HospitalHospice FacilityOther

If other : Name

DOES THE INDIVIDUAL HAVE A SPOUSE? YesNo

IF Yes, Spouse Name

Is spouse in need of services and supports? YesNo

Age of spouse?

Is there a friend/family caregiver or emergency contact that needs to be contacted? YesNo

If yes, provide contact information (if known):

Legal Guardian YesNoUnknown

Representative Payee YesNoUnknown

Power of Attorney for Health YesNoUnknown

Power of Attorney for Financial YesNoUnknown

If yes, provide contact information (if known)

Is there a friend/family caregiver or emergency contact that needs to be contacted? YesNo

If yes, provide contact information (if known)

Is there any other individual at this residence that needs services and supports? YesNo

NOTE: If yes, complete a separate referral form if 60 or over. If under 60, refer to the proper state agency.

Name of other individual (if known):

Age of other individual (if known):

Does the Individual have: Hearing loss? YesNoUnk

Vision Issues? YesNoUnk

If yes, preferred method of communication (i.e., Interpreter, TTY Relay Services or Braille Assistance):

Alzheimer’s or any other type of dementia? YesNoUnknown

Mental Health Illness? YesNoUnknown

Physical Disability? YesNoUnknown

Intellectual/Developmental Disability? YesNoUnknown

Brain Injury (i.e., stroke, head injury, aneurysm)? YesNoUnknown

Reason for Referral (general concerns): Please provide any additional information regarding the Individual in
need of supports and services that may be helpful.

Does the Individual receive any supports and services now? YesNo

If yes, type of supports and services are received:

Is the Individual experiencing any problems with the current supports and services? YesNo

Please explain

Has the Individual or spouse served in the military? YesNo

Is the Individual aware of the referral? YesNoUnknown

Is the Individual in immediate danger? YesNoUnknown

Explain:

Is the Individual in need of immediate assistance? YesNo

Explain:

Does the Individual want someone else to be present during the home visit? YesNo

Time

Phone:

Email: