Chicago



438785-19050000Referral Form for Services and SupportsReferral Date: 4/25/2018Time: DATE \@ "h:mm am/pm" 3:53 PMAgency Name: FORMTEXT ????Staff Person Taking Referral: FORMTEXT ?????person making the referral:Name: FORMTEXT ?????Phone: ( FORMTEXT ???) FORMTEXT ????? FORMCHECKBOX Cell FORMCHECKBOX Home FORMCHECKBOX Work E-mail: FORMTEXT ?????Relationship to Individual in need of supports and services: FORMTEXT ?????individual in need of services and supportsName: FORMTEXT ?????Age: FORMTEXT ???Date of Birth: FORMTEXT ?????Address: FORMTEXT ?????City: FORMTEXT ????? Zip Code: FORMTEXT ?????County: FORMTEXT ?????Phone: ( FORMTEXT ???) FORMTEXT ????? FORMCHECKBOX Home FORMCHECKBOX Work FORMCHECKBOX CellE-mail: FORMTEXT ?????If not English-speaking, preferred language: FORMTEXT ?????Do you live alone? FORMCHECKBOX Yes FORMCHECKBOX NoSafety issues (i.e. dogs)? FORMCHECKBOX Yes FORMCHECKBOX NoPlease describe: FORMTEXT ?????If not a home residence, please indicate the name and type of facility where the Individual is located.Facility Name: FORMTEXT ?????Facility Address: FORMTEXT ????? FORMCHECKBOX Assisted Living FORMCHECKBOX Supportive Living Program FORMCHECKBOX Long-term Care Facility (Nursing Home) FORMCHECKBOX Hospital FORMCHECKBOX Hospice Facility FORMCHECKBOX Other: Name: FORMTEXT ?????Does the individual have a spouse? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Spouse Name: FORMTEXT ?????Is spouse in need of services and supports? FORMCHECKBOX Yes FORMCHECKBOX NoAge of spouse? FORMTEXT ???Is there a friend/family caregiver or emergency contact that needs to be contacted? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, provide contact information (if known): FORMTEXT ?????Does the individual have any of the following?Legal Guardian FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownRepresentative Payee FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownPower of Attorney for Health FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownPower of Attorney for Financial FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf yes, provide contact information (if known): FORMTEXT ?????Is there a friend/family caregiver or emergency contact that needs to be contacted? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, provide contact information (if known): FORMTEXT ?????Is there any other individual at this residence that needs services and supports? FORMCHECKBOX Yes FORMCHECKBOX NoNOTE: 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): FORMTEXT ?????Age of other individual (if known): FORMTEXT ?????Health Information:Does the Individual have: Hearing loss? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unk. Vision Issues? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unk.If yes, preferred method of communication (i.e., Interpreter, TTY Relay Services or Braille Assistance): FORMTEXT ?????Has the Individual been told by a health care professional that they have any of the following?Alzheimer’s or any other type of dementia? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownMental Health Illness? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownPhysical Disability? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIntellectual/Developmental Disability? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownBrain Injury (i.e., stroke, head injury, aneurysm)? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownAdditional information regarding the individual in need of supports and servicesReason for Referral (general concerns): Please provide any additional information regarding the Individual in need of supports and services that may be helpful. FORMTEXT ?????Does the Individual receive any supports and services now? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, type of supports and services are received: FORMTEXT ?????Is the Individual experiencing any problems with the current supports and services? FORMCHECKBOX Yes FORMCHECKBOX NoPlease explain: FORMTEXT ?????Has the Individual or spouse served in the military? FORMCHECKBOX Yes FORMCHECKBOX NoIs the Individual aware of the referral? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIs the Individual in immediate danger? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownExplain: FORMTEXT ?????Is the Individual in need of immediate assistance? FORMCHECKBOX Yes FORMCHECKBOX NoExplain: FORMTEXT ?????Does the Individual want someone else to be present during the home visit? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, who: FORMTEXT ?????What would be the best time and method to contact the Individual (if known):Time: FORMTEXT ?????Phone: ( FORMTEXT ???) FORMTEXT ?????E-mail: FORMTEXT ????? ................
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