This form is intended to facilitate the referral process that you, as a professional, are undertaking on behalf of your client. If you are unsure of eligibility requirements, call RFS at 919-872-7933 to speak to an Intake Specialist. We cannot screen your clients through this form!

For the cost-share programs, your client must be a resident of Wake County, 18+ years of age, and have personal care needs, NOT just housekeeping/meal prep. An Intake specialist, at the above number, can assist you in screening your client if you are unsure whether yours would be an appropriate referral.

Please complete ALL information requested. NOTE: Due to state requirements, we now need additional demographic info to place clients on 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 #:

Diagnoses:

ADL requirements:

ADLS
Bathing
Grooming
Dressing
Toileting
Ambulation
Transfer
Eating/Feeding
Medication Management

IADLs
Communication
Telephone
Transportation
Shopping
Housekeeping
Laundry
Meal Preparation

IMPORTANT: 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 and has been notified of the waiting list for this program. 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:

SPEED REFERRAL for Cost-Shared In-Home Care (Wake Independence at Home and Respite) FAX: 919-872-9574

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

SPEED REFERRAL
for Cost-Shared In-Home Care
(Wake Independence at Home and Respite)
FAX: 919-872-9574