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!
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!
|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 #:|
NOTE: This information is used to establish priority in the event of a wait list.
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
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.
|Phone# where message can be left for you (no pagers accepted):|