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SERVICING GWINNETT COUNTY, GEORGIA

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REFERRAL
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Referral Information

Date of Referral*

Referred By (Agency/Individual)*

Contact Person*

Phone Number*

Email Address*

Client Information

First name*

Last name*

Gender*

Phone Number*

Email Address*

Current Address*

Current Living Situation

Single choice*

Living with a friend

In a car

Shelter

Homeless

Hospital

Shared Living

Other:

Health & Support Needs

Is the client currently taking medications?*

YES

NO

Does the client have any disabilities or special needs?*

NO

If YES, please describe:

Does the client require assistance with any of the following?

Meals

Housekeeping

Transportation

Medication Reminders

Mental Health Diagnosis (if applicable):

Primary Physician Name

Primary Physician Phone Number

Mobility Aids Used

Cane

Walker

Wheelchair

Other:

Financial Information

Income Source*

SSI

SSDI

Retirement

Employment

Other:

Monthly Income Amount*

Proof of Income Provided*

YES

NO

File upload

Responsible Party for Billing (if different):

Name:

Contact Info:

Background Information

Substance Abuse History:*

YES

NO

Ex-Offender:*

YES

NO

Sex Offender Conviction:*

YES

NO

On Probation or Parole:*

YES

NO

Placement Details

Date Client Needs to Be Placed:*

Room Preference:*

Private

Shared

Tell us about the client’s goals or support needs:*

Referral Authorization

I confirm that the information provided above is accurate and that the client is being referred for independent living services at On My Sisters Behalf Independent Living Facility.

Referring Party Signature*

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Today's Date*

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