Provider Referral Form
This form is only for those that live in the Jefferson County Area.
Are you a health care provider making a referral?
Yes
No
Provider First Name:
Provider Last Name:
Provider Email:
Provider Phone #:
First Name:
Last Name:
Phone Number:
Email Address:
Relationship to client:
Client Information
First Name:
Last Name:
Phone Number:
Date of Birth:
Gender:
Please select...
Male
Female
Prefer not to say
Race:
Please select...
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Client's Address:
City:
State:
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
County of Client's Residence:
Client's S.S.N (if available):
Estimated Monthly Income:
Does the client have a caregiver?
Yes
No
Caregiver's First Name:
Caregiver's Last Name:
Caregiver's Phone #:
Caregiver's D.O.B.:
Caregiver's Email:
Caregiver's Relationship to Client:
What Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) does the client need or currently receive assistance with?
Do any of the following apply to the client/individual?
Has someone help feed them or uses feeding tube
Needs assistance transferring in/out of bed, chair, toilet, etc. either through the use of caregiver or lift
Uses a walker, cane, rollator, wheelchair, grab bars to ambulate, or bed bound.
Receives help with getting dressed.
Uses a shower chair to assist with bathing or caregiver to help bathe.
Uses incontinence supplies (such as adult briefs, bed pads, and wipes) or bedside commode, or colostomy/ostomy bag, or catheter.
Needs assistance with housekeeping such as laundry, dusting, vacuuming, mopping, etc. due to disability or medical condition.
Receives/needs assistance with meal preparation.
Receives assistance managing their own money/funds from either a friend, family member, representative payee, guardian/conservator.
Receives assistance with medication management such as family or friend preparing daily medications or pharmacy packing daily medications.
Has family members or friends assist them with shopping for personal items such as toiletries and groceries.
Requires assistance with transportation either through public or private transportation due the client/individual lack of access to transportation or inability to drive.
Needs help using a telephone.
None of these statements apply to client/individual
Services Requested for client/individual - please check all that apply
.
Elderly and Disabled Waiver Program
Food Assistance
Senior Center Meals
Meals On Wheels
Caregiver Support
Homemaker Services
Personal Care Services
Health and Wellness
Legal Assistance
Long Term Care Advocacy and Information for residents in facilities
Medicare Counseling
Prescription Assistance
Older Relative Raising Children/Grandparent Support Group
Other
Additional Information:
Contact Information