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 or services offered, you must call Resources For Seniors at 919-872-7933 to speak to an Intake Specialist.
Our Housing and Home Improvement Department may be able to help your clients make health and safety modifications to their homes. Certain types of home repair and adaptation may be covered under a sliding fee scale. RFS Renovation and Repair is also a licensed general contractor, offering a wide variety of services on a private pay basis, to the entire community.
Please note that there is now a different referral form for clients needing either wheelchair ramps or hot water heaters.
Please complete that form instead for those clients.
Is your client:
The following information must be completed in its entirety. Any incomplete information will void the referral.
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!
|Date of Birth:|
|Best time to call:|
|Monthly HOUSEHOLD Income*:|
|How many people in the household?|
|Who owns the residence?|
*If client wishes to be considered for any sliding-scale fee programs, monthly income MUST be provided. If monthly income is not provided, it will be assumed that the client intends to pay privately for services. There will be no exceptions.
Work request (please be specific):
Anything else we should know? Who should we contact, client or caregiver? Are there other contact people we should know about? Any communication barriers?
|Does client own the residence?||Yes No|
If client is renting, it is his/her responsibility to obtain written permission from the landlord before Resources for Seniors may complete any work.
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 the waiting list status of this program.
|Phone# where message can be left for you (no pagers, please!):|
How did you hear about RFS/HHI?