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!
|Date of Birth:|
|Social Security Number, Last 4 Digits Only:|
|Hispanic/Latino? (Yes or No):|
|Primary Language Spoken:|
|Caregiver or Contact Name:|
|Address(if different from above):|
|# living in home:|
|Monthly Income of the Client ONLY:|
|Monthly Income of Household (couples only):|
|Physician's Phone #:|
|Is a Health Care Provider Referring Client for Ramp (Yes/No):|
Major Medical Diagnoses:
NOTE: This information is used to establish priority in the event of a wait list.
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
Does the client have help with any of the above? Check both if they have both kinds.Paid help
Does the client have significant memory loss or confusion?Yes
Is the client in need of a ramp or a water heater?Ramp
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.
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.
|Phone# where message can be left for you (no pagers accepted):|