Client's Personal Information:
Client Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Gender
*
Male
Female
Prefer Not To Say
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Medical Information:
Primary Diagnosis/Condition(s)
Medications currently being taken (name, dosage, frequency)
Allergies
Dietary restrictions
Physician's contact information
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Physical Abilities and Mobility:
Level of assistance required for transferring and ambulating
independent
supervision
full assistance
Use of any mobility aids (walker, cane, wheelchair, etc.)
Fall risk assessment
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Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs):
Level of assistance required for each ADL and IADL, including bathing, dressing, grooming, toileting, feeding, meal preparation, medication management, housekeeping, laundry, and transportation
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Cognitive and Emotional Status:
Level of cognitive function (memory, problem-solving, decision-making)
Presence of any cognitive impairment or dementia
Emotional well-being and mood
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Communication:
Ability to communicate effectively (verbal, written, or other methods)
Language preferences
Hearing and vision abilities
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Preferred Schedule and Frequency of Care:
Preferred days and times for caregiver visits
Desired frequency of care (daily, weekly, etc.)
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Goals and Expectations for Care:
Client's and family's goals and expectations for the care provided
Zip Code
Primary Diagnosis / Reason for Referral
Minor
Emancipated Adult
Has Legal Guardian
Legal Guardian Name (if applicable)
First Name
Last Name
Relationship to Client
Primary Contact Information
Primary Contact Name
First Name
Last Name
Relationship to Client
Primary Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Case Manager / Referral Source Information (If applicable)
Organization / Agency Name
Case Manager Name
First Name
Last Name
Case Manager Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Case Manager Email
example@example.com
Services Requested
Type of Services Needed
Companionship
Personal Care
Meal Preparation
Light Housekeeping
Transportation
Medication Reminders
Other
Requested Start Date
-
Month
-
Day
Year
Date
Preferred Schedule
Hourly
Daily
Overnight
Live-in
Flexible
Payment / Funding Source
Payment / Funding Source
Private Pay
Medicaid Waiver
Veterans Benefits
Long-Term Care Insurance
If Medicaid:
Has Medicaid Waiver?
Yes
No
Type of Waiver:
FSW
CIH
A&D
TBI
If Long-Term Care Insurance:
Insurance Provider Name
Additional Information
Please share any additional details that would help us better support the client:
Consent & Submission
I confirm the information provided is accurate and I authorize Great Lengths Home Care to contact me regarding this referral.
*
I Accept.
Submit
Should be Empty: