Professional Referrals

THIS INFORMATION IS SENT ENCRYPTED AND IS SECURE.
After we receive your information it will be reviewed and sent to the appropriate department.

Items with an * asterisk are required. Referral Source * must be filled out or form cannot be submitted.

Your information as the referral source is important, should we need to contact you for additional information.

- Home Delivered Meals (must be age 60 or over, not a PCA client)

Your Information

Your information as the referral source is important, should we need to contact you for additional information.

Mandatory field First name*

Mandatory field Last name*

Mandatory field Organization or relationship to the person referred*

Mandatory field Email*

Mandatory field Phone*

Address

Address 2

City

State

Zip

Person Being Referred

Mandatory field Referred First name*

Mandatory field Referred Last name*

Mandatory field Referred Phone*

Mandatory field Referred Address*

Referred Address 2

Mandatory field Referred City*

Referred State

Referred Zip

Gender

Male Female

Do you know the date of birth?

Yes 1 No 1

Date of Birth

Mandatory field MassHealth*

Yes 2 No 2 Don't know

If yes, MassHealth ID

Primary Language Spoken

Marital Status

Married Partnered Single Divorced Widow/widower

Lives with

Additional Items

Aware of the referral

Is this person aware of the referral?

Yes 3 No 4

Call Referred

If we should not contact the person being referred who should be call?

Mandatory field First name.*

Mandatory field Last name.*

Relationship of person being referred

Mandatory field Phone.*

Primary emergency contact / caregiver

.First name

.Last name

.Phone

Consumer's Medical Information

Primary care physician

Physician's phone

Current medical conditions (list all that apply)

What activities of daily living (I/ADLs) does the consumer need help with? Please be as specific as possible.

Is the consumer currently receiving services? If so, please list.

Mandatory field Reason for Referral (Why Services Are Needed) please include facility discharge date if known*

If you know what you are looking for, select programs being requested

Home Delivered Meals Home Delivered Meals (must be age 60 or over, not a PCA client.)

State Home Care State Home Care (must be age 60 or under 60 with a documented diagnosis of Alzheimer's or a related dementia)

Family Caregiver Support Program Family Caregiver Support - Caregiver must be age 18+ caring for person age 60+ w/without ADRD, Grandparent age 55+ caring for child 0-18 or disabled 18-59.

Options Counseling Program (copy) Options Counseling Program-For Adults age 60+ or Adults w/ disabilities seeking to explore long term care services and resources

For the following services, the person you are referring must have MassHealth Standard or CommonHealth AFC - Adult Foster Care (age 16 or older; must have at least 1 ADL need. Medication management is NOT an ADL qualifier. Consumer must NOT be able to live safely alone in the community) Personal Care Management (any age, must need HANDS-ON assistance with at least 2 ADLs; hands-on medication management DOES count for program eligibility)

Mandatory field Security Question* Please add 5 and 6.

Do not fill in this field

For GSSSI staff who are making an internal referral:

(Please click the link below)

https://fs30.formsite.com/GSSSI/gwnwfmeduk/index.html