Care Coordination Referral Form PERSON MAKING THE REFERRALWho is the referral for:MyselfSomeone elseI am a professional making a referralName First Last PhoneType Cell Home Work Email Relationship to the person receiving the referral: INDIVIDUAL NEEDING SUPPORTS AND SERVICESPlease use the fields below to identify the individual needing Care Coordination services.Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Phone Number(Required)TypeHome PhoneCell PhoneCaregiver's PhoneBest time to call:8:00 am12:00 pmAddress(Required)Must be located in DeKalb County, IL. Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email English SpeakingYesNoUnknownLanguage used: Current Environment(Required) Own home or apartment (independent living) Assisted Living Supportive Living Program Hospital Hospice facility Long-term Care Facility (nursing home) Please indicate the name of the facility: OTHER INFORMATIONMarital Status Married (domestic partner) Not married or with domestic partner Other Is the spouse or domestic partner in need of supports and services? Yes No Unknown Military Service (self or spouse) Yes No Unknown Who Served: The individual Their spouse Unknown Military Branch Army Marine Corps Navy Air Force Space Force Coast Guard National Guard Current Legal Documents and Supports Legal Guardian Unpaid caregiver Paid caregiver Emergency contact Healthcare Power of Attorney Financial Power of Attorney Representative Payee Does the caregiver or emergency contact need to be contacted? Yes No Unknown If yes, provide their name and phone number: Health Information Hearing loss Vision loss Alzheimer's or other type of dementia Mental health illness Physical disability Intellectual disability Developmental disability Brain injury (stroke, head injury, aneurysm...) Preferred method of communication:(Interpreter, TTY relay, video relay, braille...) REFFERAL INFORMATIONReason for Referral(Required)Please provide additional information regarding the individual in need of supports and services that may be helpful.Are there known safety issues at home?Example: animals, hoarding, guns... Yes No Unknown Please describe: Does the individual receive any supports and services now? Yes No Unknown Type of support and services received: Is the individual experiencing problems with their current supports and services? Yes No Unknown Please explain:Is the individual in immediate danger? Yes No Unknown Is the individual in need of immediate assistance? Yes No Unknown Is the individual aware of the referral? Yes No Unknown Does the individual want someone else to be present during the home visit? Yes No Unknown CommentsThis field is for validation purposes and should be left unchanged.
