This form is intended to facilitate the referral process that you, as a professional, are undertaking on behalf of your client.

For the CAP program, your client must be a resident of Wake County, 18+ years of age, at a nursing home level of care, at risk for nursing home placement related to care needs, and eligible for Medicaid. An Intake specialist, who can be reached by calling 919-872-7933, can assist you in screening your client if you are unsure whether yours would be an appropriate referral.

The following information must be completed in its entirety. Any incomplete information will void the referral. We will NOT call you or the client to get missing information.

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:
SSN:	Please call RFS Intake with this info -- 919-713-1556. This referral will not be entered on the wait list until we receive this information.
Caregiver or Contact Name:
Address(if different from above):
City:
State:
Zip:
Phone:
Relationship:
# living in home:
Monthly Income of the Client ONLY:
Physicians Name:
Physician Phone #:
Does client have Medicaid already?
If so, Medicaid #:	Please call RFS Intake with this info -- 919-713-1556

Diagnoses:

ADL requirements:

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

IADLs
Communication
Telephone
Transportation
Shopping
Housekeeping
Laundry
Meal Preparation

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 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:

How did you hear about RFS/CAP?