Referral Intake Form Client InformationFull Name *Date of Birth *Age *Gender *MaleFemaleOtherList Other Gender *0 / 25Social Security Number *0 / 11Street Address *Apartment, suite, etcCity *State *ZIP *Phone *Email Address *Select *Primary LanguageEnglishSpanishChineseFrenchOtherList Other Language *Emergency Contact Name *Emergency Contact Relationship *Emergency Contact Phone *Medical InformationPrimary Care Physician Name *Physician Phone *Physician Address *Apartment, suite, etcCity *State *ZIP *Specialist(s) Involved in Care (if applicable)NamePhoneNamePhoneCurrent Medications (Include dosages) *Known Allergies *Primary Diagnosis *Secondary Diagnoses (if applicable)Physical Limitations/Disabilities *Current Functional Status *IndependentRequires AssistanceDependentIs the individual mobile? *YesNoDoes the individual have any cognitive impairments? *YesNoAdmission CriteriaReason for Referral *Health or Medical Needs Requiring Care *Please describe any specific health concerns, such as medication management, physical therapy, etc.Dietary Requirements/Restrictions *How many days of care are needed? *Does the individual have a history of mental health issues? *YesNoPlease provide details *Is the individual interested in receiving mental health services? *YesNoDoes the individual require any additional services? *Individual TherapyGroup TherapyMedication Evaluations/ManagementCase Management SupportRehabilitative Services (As needed)Insurance & Financial InformationInsurance Provider *Policy Number *Subscriber NameIf different from clientInsurance Contact InformationPhone *Fax *Medicare/Medicaid Number (if applicable)Primary Payment Source *MedicareMedicaidPrivate InsuranceSelf-payOtherList other payment source *Consent and AcknowledgmentI hereby authorize the Adult Medical Daycare facility to obtain and exchange necessary medical and other information regarding my care with my medical providers and the designated emergency contacts listed above.Signature of Referring Individual/Guardian *Start signing your signature hereYour browser does not support e-Signature field.Date *Referring Healthcare Provider InformationReferring Provider Name *Provider's Contact Information:Phone *Fax *Provider's Address *Apartment, suite, etcCity *State *ZIP *Additional InformationPlease provide any other relevant information or requests needed for the individualSubmit Form
