A Free Senior Referral Service

Licensed by California Department of Public Health
Administrators Certified by Department of Social Services

Referral Request Form

Please fill out this form to the best of your ability. Required Items are shown in Red.
After this form is received by Elderlink a Care Counselor will assess the information you have provided and based on that evaluation create a list of appropriate facilities that will meet the individual's needs. Please provide as much information as possible, if we have further questions we will contact you.

Your privacy is important to us. Any information you provide will be held in strictest confidence. We WILL NOT use any information on this form except as required to respond to your request.

Your Contact Information

Your First Name:

Your Last Name:

Your Address:

City:

State:

Zip:

Second Contact:

Second Contact - Relationship to Senior:

Home Phone Number (please provide at least one phone contact number):

Business Number:

Cell Phone:

Fax:

Email Address:

What is your relationship to the senior?:

Senior's Information

Senior's First Name:

Senior's Last name:

Sex:

female male

Age:

Date of Birth:

If this is a couple Name of Second Person:

Sex:

female male

Age:

Date of Birth:

Presently living where?

Home With Relatives Facility

If presently living at facility,
please indicate name:

Diagnosis:

Heart disease	Alzheimer’s Disease
Stroke	Parkinson’s Disease
Emphysema	Mental Illness
Dementia	Diabetic
TIA’s	Depression
Healthy	Multiple Sclerosis
Congestive Heart Disease
Macular Degeneration
Short Term Memory Loss
Other?

Assistance needed:

Bathing	Walking
Dressing	Injections
Medications	Catheter
Incontinence	Colostomy
Toileting	Feeding
None	Self Sufficient

Fill in the following if applicable:

Self Sufficient	Oxygen
Forgetful	Wanderer
Confused	Tube Feeding
Cane	IV
Walker	Aphasia
Wheelchair	Smoker
Electric cart	Pets
Bedridden
Blind
Partially Sighted
Deaf
Hard of Hearing

Additional Information

What type of Facilities are you looking for:

Type of Room Desired?:

What is the monthly budget?
(Select from drop down list
or fill in amount)

Location

Location Desired(city)?:

Zip Code

Radius of miles from Zip

How soon do you need placement?

How did you hear about Elderlink?

Other?

May a facility contact you for questions?

yes no

May a facility send you a brochure?

yes no

To best serve you, please indicate any facilities you have seen or contacted to avoid duplication

Additional Information or Comments

A Free Senior Referral Service

Licensed by California Department of Public Health Administrators Certified by Department of Social Services

Referral Request Form

Licensed by California Department of Public Health
Administrators Certified by Department of Social Services