Special Recreation Services Waiver Services Referral Form
Please contact Christina if you have any questions. christina@specialrecreationservices.org or 570-269-0041
Today's Date
*
-
Month
-
Day
Year
Date
Individual's Name
*
First Name
Last Name
Individual's Birthdate
*
In which county does the individual reside?
*
Which service(s) is the individual interested in?
*
CPS 1:1 (services provided 100% in the community. We do not have a facility)
In Home and Community Supports
Support's Coordinator Name
*
First Name
Last Name
Supports Coordinator's Agency
*
Supports Coordinator Email
*
example@example.com
Supports Coordinator Phone Number
*
Please enter a valid phone number.
What is the individual's current funding stream?
Consolidated
Community Living
P/FDS
SC only
Other
How many hours a week?
*
Any particular days of the week?
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Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Client is flexible
Can the individual be unsupervised while staff uses the bathroom?
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Yes
No
Can the individual fully use the bathroom by him/her self ? (meaning staff do not have to help them wipe or help the women during menstruation)
*
Yes
No
If you answered no in the above box, please explain more in detail about the individual's toileting needs.
Type of staff the individual prefers:
*
Female
Male
No preference
Please attach the individual's ISP.
*
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