TGP Referral Form

Referral Form for Adult Day Services

Please fill out this secure form to provide preliminary intake information or refer someone to our Adult Day Program. This form can be completed by any interested party.
Referrer Information
Your Full Name*

First NameLast Name
Your Relationship to the Individual Being Referred*
Organization Name*
Your Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Your Email Address*
example@example.com
Individual Being Referred
Full Name of Individual*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Current living situation*
Functional Status/Activities of Daily Living (ADLs) individual may need assistance with (check all that apply)*

BathingDressingEatingToiletingTransferringWalkingGroomingUses mobility device (cane, wheelchair, rollator)Uses incontinence pads or briefsNone/IndependentOther
General information on diagnoses, medical conditions and cognition*
Who should we contact to follow-up on this referral?*

Myself/referring individualPlease contact participant directlySomeone else (family, friend, case manager, etc)
Who should we contact?*

First NameLast Name
Relationship to the Individual Being Referred*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
How Soon is the Individual Looking to Start Services?*
Is the individual interested in a tour of the facility at this time?*

YesNoAlready completed
Additional Comments or Questions
General information regarding program fees:

The Gathering Place current published hourly charge is $26.28 per hour, billed in 15 minute increments.

Participants pay for their services many ways. Examples include:
- Vermont Medicaid (including Choices for Care and Developmental Services Waiver).
- Respite Grant funding
- Private Pay or Long-term care insurance
- Sliding fee subsidy. Sliding fee subsidies may cover up to 50% of program fees based on an evaluation of income and assets. It is important to note that sliding fee subsidies are limted to available funding and availabillity is not guaranteed.
Program fees are not covered by Medicare.

More information on payment options and fees will be provided during the enrollment process.
This institution is an equal opportunity provider.

No individual shall be excluded from participation in or be denied the benefits of The Gathering Place by reason of age, disability, race, gender, sexual orientation, religion, national origin or any other protected status.
Should be Empty:

Referral Form for Adult Day Services

Referrer Information

Individual Being Referred