Mercarik: Referral Form

Mercarik Referral Form
Integration User ID
None Account ID
Record Type ID
Is this referral a SAFETY EMERGENCY? (prioritized scheduling 4-6 weeks out - additional $200)

YesNo
Individual Information

Enter information for the person you are making the referral for. Please skip the question if it does not apply to the person you are making the referral for.
Name*

Individual's First NameIndividual's Last Name
Date of Birth*

MonthDayYear
Please enter the individual's birthday.
Individual's Landline
Please enter the individual's phone number, if applicable. (Please do not enter contact information for the CM or a family member here)
Individual's Mobile Number
Please enter the individual's cell number, if applicable. (Please do not enter contact information for the CM or a family member here)
Individual's Email Address
Please enter the individual's email, if applicable. (Please do not enter contact information for the CM or a family member here)
Which of the following most accurately describes the individual? Choose as many as you like.

MaleFemaleNon-BinaryTransgenderIntersexLet Me TypeI Prefer Not to Say
Let Me Type - response
Interpreter Needed?*

YesNo
Interpreter Type(s) Needed?

ASLSomaliSpanishTactileOther
Interpreter(s) Needed (Other)
Please list all additional interpreter(s) needed
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Are There any Safety Concerns our Staff Should Know About?*

NonePhysical ViolenceSpecific TriggersHistory of Paranoia/DelusionOther
Safety Concern Follow Up*
Please provide as much detail as our staff will need to know when conducting the assessment
Are There Any Environmental Factors our Staff Should Know About?*

YesNo
Environmental Factors Follow Up*
Please provide as much detail as our staff will need to know when entering the home.
Reason for Referral (can choose more than 1)*

In-home AT AssessmentTablet/Laptop AssessmentAT InstallationProduct OrderingAutomatic Door Opener
Reason for Tablet/Laptop Assessment
The more information we have, the better we can match the person with the best first step.
Reason for Installation
The more information we have, the better we can match the person with the best first step.
Product Ordering Items
The more information we have, the better we can match the person with the best first step.
Reason for Automatic Door Opener Request
The more information we have, the better we can match the person with the best first step.
Reason for Referral*

The more information we have, the better we can match the person with the best first step.0/30000
Individual Billing Information

Which waiver or FMS does funding come from?
Insurance ID/PMI*
Funding type(s)*

Traditional WaiverCDCSPrivate Pay
FMS Organization Name
FMS Contact Name

First NameLast Name
FMS Contact Name (Outdated)
FMS Email Address
example@example.com
Error! You will not be able to submit until this error is corrected.

The Email for FMS Contact should not be the same as the Individual.

Please return to the Individual's Email and enter the Individual's Email, if applicable. You can leave it blank if they do not have one.
FMS Email Address (Outdated)
example@example.com
FMS Phone Number
Case Manager Information
Case Manager Name*

First NameLast Name
Organization / County
Case Manager Name (Outdated)
Case Manager Phone
Please enter a valid phone number.
Case Manager Email*
example@example.com
Error! You will not be able to submit until this error is corrected.

The Email for Case Manager should not be the same as the Individual.

Please return to the Individual's Email and enter the Individual's Email, if applicable. You can leave it blank if they do not have one.
Case Manager Email (Outdated)
example@example.com
Scheduling

Who should we reach out to coordinate scheduling an appointment with the individual, if needed?
Scheduler is Individual?*

YesNo
Scheduling Contact Name

First NameLast Name
First and Last Name
Best person to schedule assessment/installation with?
Relationship to Individual
Relationship to Individual (Outdated)
Scheduler Cell Phone Number
Please enter a valid phone number.
Scheduler Landline Number
Please enter a valid phone number.
Scheduler Email Address
example@example.com
Will this person be present at the appointment?

YesNoOther
Error! You will not be able to submit until this error is corrected.

The Email for Scheduler should not be the same as the Individual.

If the Scheduler is the Individual, please select 'Yes' for 'Scheduler is Individual' question above. Otherwise, please return to the Individual's Email and enter the Individual's Email, if applicable. You can leave it blank if they do not have one.
Email Address (Outdated)
example@example.com
Best Way to Reach Scheduler?

Phone Call - CellPhone Call - LandlineTextEmail
Best Way to Reach Individual?

Phone Call - CellPhone Call - LandlineTextEmail
Should be Empty:

Mercarik Referral Form

Individual Information

Individual Billing Information

Case Manager Information

Scheduling