This form is intended to facilitate the referral process that you, as a professional, are undertaking on behalf of your client. You may print it, fill it out, and fax it to us, or you may fill it out and email it to us. If you are unsure of eligibility requirements, you have an obligation to call RFS at 919-872-7933 to speak to an Intake Specialist. We cannot screen your clients through this form!

Please complete ALL information requested. NOTE: Due to state requirements, we now need additional demographic and care info to prioritize clients if there is a waiting list. Please do not leave these fields blank! Incomplete referrals will not be processed.

HINT: Use your mouse or tab key to move from one field to another. Using the Enter/Return key will cause the form to be submitted prematurely!

Client Name:
Address:
City:
State:
Zip:
Phone:
Date of Birth:
Social Security Number, Last 4 Digits Only:
Race:
Hispanic/Latino? (Yes or No):
Marital Status
Primary Language Spoken:
Caregiver or Contact Name:
Address(if different from above):
City:
State:
Zip:
Phone:
Relationship:
# living in home:
Monthly Income of the Client ONLY:
Monthly Income of Household (couples only):
Physician's Name:
Physician's Phone #:
Is a Health Care Provider Referring Client for Ramp (Yes/No):

Major Medical Diagnoses:

Activities of Daily Living (Check if client CANNOT do activity without assistance):

NOTE: This information is used to establish priority in the event of a wait list.

ADLS
Bathing
Dressing
Grooming (brushing teeth, hair, shaving)
Managing bathroom needs
Eating if food is provided
Moving around the house on foot
Getting into/out of bed or chair

IADLs
Money Management
Medication Management
Shopping
Heavy Housework
Light Cleaning
Meal Preparation
Transportation
Use Telephone
Communicate needs

Does the client have help with any of the above? Check both if they have both kinds.

Paid help
Unpaid help (family or friends)

Does the client have significant memory loss or confusion?

Yes

Is the client in need of a ramp or a water heater?

Ramp
Water Heater

If the referral is for a RAMP, please check one of the following:

Client cannot enter or leave the house. More than one person would be needed to help client into/out of the home.
Client can use steps to enter or leave the house with one person's help.
Client can use steps to enter or leave the house without help if needed but has difficulty and needs ramp for safety or convenience.

Further description of need:

Anything else we should know? Who should we contact, client or caregiver? Are there other contact people we should know about? Any communication barriers?

By making this referral, you are certifying that the above information is correct to the best of your knowledge, and that the client is aware of your actions on his/her behalf. If you have any questions related to this referral, please call an Intake Specialist at 919-872-7933.

Your Name:
Organization:
Phone# where message can be left for you (no pagers accepted):
Your Email: