* = Required Information
Referring Person's Name
First Name
*
Last Name
*
Referring Person's Relationship to Individual
*
Phone Number
*
Email
*
Name/Initials of Person Being Referred
First Name
*
Last Name
*
Age
*
Sex
*
Male
Female
County of Financial Responsibility
*
Location of Desired Placement
*
Primary Diagnosis
*
Need Accessible Home
*
Yes
No
Level of Care Desired (adult foster care or supported apartments)
*
Does the person have a waiver (CADI, DD, or BI)? The waiver funds the program/staffing.
Yes
No
Guardianship Status
No guardian (own guardian)
Has a guardian - family member
Has a guardian - private/paid guardian
Describe any significant health issues (diabetes, TB, etc.), ambulation (walking) issues, or sensory issues (blind, deaf, etc)
Behavioral History - Please describe the behaviors that have presented a problem for the person, including the frequency and intensity. Include behaviors such as: physical aggression, verbal aggression, drug or alcohol abuse, sexual offending, med non-compliance, self harm, elopement from supervision, etc.
Is the person under civil commitment? Is the person on probation or parole? Please describe.
Additional Comments
Submit