Community Living Connections (CLC) Referral Form
Please complete the information below and the CLC team will follow up with the client to conduct an initial needs screening and provide Information & Assistance or Care Coordination as indicated.
Referral Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client Name
First Name
Last Name
Age
Date of Birth
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Gender
Race/Ethnicity
Preferred Language(s)
Household Monthly Income
Is the client a caregiver?
Yes
No
Brief summary of the client's situation, presenting issues and what the client needs:
What Activities of Daily Living (ADLs) does the client need assistance with?
Eating
Toileting
Walking
Transferring
Dressing
Bathing
Medication Management
What Instrumental Activities of Daily Living (IADLs) does the client need assistance with?
Cooking (Meal Preparation)
Shopping
Chores
Money Management
Driving/Transportation
Heavy Housework
Using the telephone
Do any of the following apply to the client/household?
Cognitive limitations
Smoker
Bed bugs
Weapons
Aggressive pets
Human or animal waste
Illicit substance use
Other safety concerns
Is there anyone else that is helping the client (i.e. family, friends, case manager/social worker)? Please provide contact information if possible
Optional File Upload (i.e. Nutrition Assessment)
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of
Consent for services
Client is aware of referral and consents to the use of confidential information to plan, provide, and coordinate services, payments, and benefits or for other purposes authorized by law. Client consents to information shared verbally or electronically, by mail or by hand delivery.
Referrer Name
Referrer Relationship
Referrer Contact Information
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Should be Empty: