ERHS Referral Intake Form

ERHS Referral Intake Form
Section 1: Client & Referral Information
Instructions
Referral Source Type
Date of Referral

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referral Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Section 2: Client Information
Name of Client

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2
CityStateZip Code
Client Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex
Marital Status
Race
Payment Method
Case manager/Social Worker (if applicable)

First NameMiddle NameLast Name
Family Caregiver Name

First NameMiddle NameLast Name
Family Caregiver Relationship
Family Caregiver Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Section 2: Service Requested
Date of Service to Start

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Estimated Length of Services (Monthly)
Service/Hours Requested Per Day
Section 3: Home Health Aide Assignment
Service Level Requested
Other Service Type — Specify
Preferred Caregiver Gender
Preferred Language
Requested Days
Schedule
Specific Duties Requested
Section 6: Physician & Medical Information
Physician

First NameLast Name
Physician Phone
Please enter a valid phone number.Format: (000) 000-0000.
Diagnosis/Medical Conditions
Allergies
Dietary Needs
Section 7: Travel & Logistics
Accessible via Public Transportation?
Travel Directions
Pets
Breed Type
Parking
Section 8: Comments & Sign-off
Comments/Miscellaneous
Name of Person Preparing the Intake

First NameLast Name
Acknowledgements
Signature
Date of Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

ERHS Referral Intake Form

Section 1: Client & Referral Information

Section 2: Client Information

Section 2: Service Requested

Section 3: Home Health Aide Assignment

Section 6: Physician & Medical Information

Section 7: Travel & Logistics

Section 8: Comments & Sign-off