• Choice in Aging's logo. (link goes to website)

  • The Bedford Center for Adult Day Health Care (ADHC)

    REFERRAL FORM

  • CLIENT INFORMATION

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Race / Ethnicity*
  • Preferred Language*
  • Limited English Proficiency?*
  • Current Living Situation*
  • Sex at Birth*
  • Gender*
  • Sexual Identity*

  • REFERRAL INFORMATION

  • Format: (000) 000-0000.
  • Risk Urgency Level*
  • Is the client aware of this referral?*
  • Do you wish to remain anonymous?*
  • Format: (000) 000-0000.
  • Ambulation*

  • ACTIVITIES OF DAILY LIVING

    Rating Scale:

    1 - Independent
    2 - Verbal Assistance
    3 - Some Human Help
    4 - Lots of Human Help
    5 - Dependent
    6 - Decline to State

  • Eating
  • Dressing
  • Bathing
  • Transferring In/Out of Chair
  • Walking
  • Toileting

  • INSTRUMENTAL ACTIVITIES OF DAILY LIVING

    Rating Scale:

    1 - Independent
    2 - Verbal Assistance
    3 - Some Human Help
    4 - Lots of Human Help
    5 - Dependent
    6 - Decline to State

  • Meal Prep
  • Shopping
  • Medication Management
  • Money Management
  • Using Telephone
  • Transportation
  • Light Housework
  • Heavy Housework
  • Diet*
  • Problems with Swallowing?*
  • Financial Coverage*
  • Below Federal Poverty Level?*
  • Medi-Cal?*
  • Medi-Cal Issue Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Transportation*
  • Enrolled in Silver Ride?*

  • Call (925) 938-7433 or (925) 676-7500 to enroll.

  • Psychiatric Diagnosis?*
  • Psychiatric Provider?*
  • Has the client had a TB test within the last year?*
  • Should be Empty: