ADRC Intake Form

ADRC Intake Form
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Date

YearMonthDay
Date
Person Making Referral

First NameLast Name
Referrer's Email
example@example.com
Referrer's Phone Number
Please enter a valid phone number.
Referrer's Company/Agency Name
Person Being Referred*

Legal First NameLegal Last Name
What County Is The Referred Person In Presently?
Enter County
Referred's Phone Number*
Please enter a valid phone number.
Referred's Street Address Line 1*
Referred's Street Address Line 2
Referred's City*
Referred's ZIP Code*
Referred's Date of Birth

MonthDayYear
Date
Referred's Social Security Number
Referred's Gender

MaleFemaleOther
Who should we contact regarding this referral?
What is the relationship to the referred?
Contact Phone Number*
Please enter a valid phone number.
What is the best time to reach you?
Select time of day.
Program Request

Assisted Living (Age restriction, 21 and older)Community Information and Referral Only (telephonic)Connected Care Ohio TelehealthLong Term Care Consultation (non Medicaid) LTCCNursing Home PlacementOhio Home Care Waiver (Age restriction, 0-59 years old)Ohio Home Care Waiver to PassportPASSPORT (Age restriction, 60 and older)Specialized Recovery Services (Age restriction, 21 and older)
Diagnosis
Areas of Assistance Needed ADL's

BathingDressingSupervision Needed d/t Cognitive ImpairmentMedication AssistanceMobilityToileting
Areas of Assistance Needed IADL's

CleaningLaundryMeal PrepShoppingTransportation
Does this person have Medicaid?

YesNo
Type of Medicaid

Health Maintenance Organization (HMO)MyCare Ohio (MCO)Other, i.e., Specified Low Income Medicare Beneficiary (SLMB) or Qualified Medicare Beneficiary (QMB)
Plan Number
Has the Referred person served in the military?

YesNo
Is there a Language Barrier or Other Communication Barrier?

YesNo
Please list Barrier
How did you hear about WRAAA?*
Additional Comments
Should be Empty: