Client Name: Phone Number of Client: Street Address Where Care Is To Be Provided From: City: Zip Code: Date of Birth: Primary Language: (***must be age 60+***) Gender : Male Female Marital Status: Does client live alone? Yes No Annual Income Level: Does client have hoarding issues? Yes No Single Married Any known firearms, animals, etc.? Yes No Below $11,490 Below $15,510 Additional Comments/Concerns: (at or below 100% FPL) (at or below 100% FPL) $11,491 or more $15,511 or more Ethnicity: Declined to state Declined to state Hispanic/Latino Not Hispanic/Latino Race (Choose One): White Vietnamese Hawaiian American Indian or Alaska Native Asian Indian Samoan Chinese Laotian Other Pacific Islander Japanese Cambodian Other Race (includes Hispanic/ Filipino Other Asian Latino) Korean Black or African American Multiple Race Guamanian Declined to State Daily Activities Independent, Verbal Cueing Standby Assist Hands On Dependent On – Help Is Needed: Needs No Help Required Required Assist Required Others For Task Eating/Feeding Self Dressing Transferring Bathing Toileting Grooming Walking Preparing Meals Shopping Managing Medicines Managing Money Using the Telephone Doing Heavy Housework Doing Light Housework Using Avail Transportation VCAAA USE ONLY Date EHP Referral Received: Approved: Yes No Date Requesting Agency Contacted: Comments: Approved EHP Service: Personal Care Homemaker Chore Food Box Grocery Voucher Home Mod &/or Sec Devices (Ownership: ) Other: Units approved: Service Date(s) Approved: Price per Unit: Vendor Selected: Date Forwarded Other VCAAA Programs (if applicable): I&A HICAP SNP MSSP CCT HomeShare Other: Comments: 8/2013
Client Name: Phone Number of Client: Street Address Where Care Is To Be Provided From: City: Zip Code: Date of Birth: (***must be age 60+***) Primary Language: Gender : Male Female Marital Status: Does client live alone? Yes No Does client have hoarding issues? Yes No Any known firearms, animals, etc.? Yes No Additional Comments/Concerns: Annual Income Level: Single Below $11,490 (at or below 100% FPL) $11,491 or more Declined to state Married Below $15,510 (at or below 100% FPL) $15,511 or more Declined to state Ethnicity: Hispanic/Latino Not Hispanic/Latino Race (Choose One): White American Indian or Alaska Native Chinese Japanese Filipino Korean Vietnamese Asian Indian Laotian Cambodian Other Asian Black or African American Guamanian Hawaiian Samoan Other Pacific Islander Other Race (includes Hispanic/ Latino) Multiple Race Declined to State Daily Activities – Help Is Needed: Independent, Needs No Help Verbal Cueing Required Standby Assist Required Hands On Assist Required Dependent On Others For Task Eating/Feeding Self Dressing Transferring Bathing Toileting Grooming Walking Preparing Meals Shopping Managing Medicines Managing Money Using the Telephone Doing Heavy Housework Doing Light Housework Using Avail Transportation VCAAA USE ONLY Date EHP Referral Received: Approved: Yes No Date Requesting Agency Contacted: Comments: Approved EHP Service: Personal Care Homemaker Chore Food Box Grocery Voucher Home Mod &/or Sec Devices (Ownership: ) Other: Units approved: Service Date(s) Approved: Price per Unit: Vendor Selected: Date Forwarded Other VCAAA Programs (if applicable): I&A HICAP SNP MSSP CCT HomeShare Other: Comments: 8/2013
2013-14_EHP_Referral_Form.docx