Adult's CM Referral Form

Email: intake@jemcare.org

Phone: (718) 506-0721
Adult’s Health Home Referral Form
INSTRUCTIONS: This form must be completed in its entirety to allow JEMCare to verify eligibility for services.
Member's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemaleOther
Medicaid ID*
Insurance Name (If any)
Preferred Language
If Other, please specify
Phone Number*
Email
Emergency Contact Number
Address*
City*
State
Zipcode*
Type of Residence

Private ResidenceHomeless (Street/ Park/ Drop-in center)Homeless Shelter/ Emergency HousingOther
REFERRAL SOURCE INFORMATION
Referral Type*
Name of Referrer*
Name of Referral Organization
Referrer Phone Number*
Referrer Email
REASON FOR REFERRAL
Diagnosis (Check all that apply)*

HypertensionDiabetesAsthmaHeart DiseaseObesitySubstance AbuseSerious Mental Illness (SMI)HIVSickle Cell AnemiaOther
Appropriateness/Risk Factor (Check all that apply)*

Difficulty navigating system due to member’s (or guardian) physical or behavioral health condition such as transportation, hygiene, managing finances or scheduling medical appointmentDoes not have specialist to treat physical or behavioral condition or has not seen a provider e.g., PCP, BH, etc.) in the last yearDeficits related to lifestyle, illness, or treatment such as medication side effects, home environment, isolation, cognitive or mental decline like dementia, aging, hospitalization, etc.)Not adherent to or having difficulty managing treatment or certain medications.Release from medical, psychiatric, crisis stabilization, residential treatment settings or detox admission, or incarceration in the last 6 monthsCurrently impacted by violence at home or by intimate partnerNeeds assistance applying for/accessing benefits such as SNAP, SSI, Housing Support, HEAP, Cash Assistance, medical entitlements etc.Unable to access food due to financial limitations, inability to shop, dietary restrictions, etc.Currently homeless or has no stable living arrangementRecent change in guardianship/caregiver’s or guardian being institutionalized themselves
Additional Information/ History
Should be Empty:

Adult’s Health Home Referral Form

REFERRAL SOURCE INFORMATION

REASON FOR REFERRAL