Attendant Care referral form

PLEASE READ THE REFERRAL PROCESS PAGE BEFORE COMPLETING THIS FORM!

Please note: This form is secure and any information submitted will remain confidential.

Individual's Name (or Initials)

Individual's Gender/Pronouns

Individual's City of Residence

Residential setting

Independent

Family Home

Group/Foster Home

Case Manager's Name

First Name

Last Name

Case Manager's E-mail Address

Case Manager's Phone Number

(###)

###

####

Does this individual require Protective Physical Intervention, including deflection, evasion, or body positioning? If YES, know that Allies is not currently accepting referrals that require these supports. If NO, please continue completing this form.

Primary Contact for this Individual

First Name

Last Name

Relationship to Individual

(Self, Provider, Family Member, etc)

Phone

(###)

###

####

Preferred Contact Method

Which services is this individual seeking?

Attendant Care only

Attendant Care & DSA

Number of Attendant Care hours available

Number of DSA hours available (if applicable)

Service Level/Category

Does this individual have any protocols?

If yes, please list all protocols here.

Does this individual have a behavior support plan/guidelines?

What level of support does this individual need to remain safe in the community?

Desired start date

Preferred gender of provider?

Does this individual require transportation in a provider's vehicle?

Yes

Doesn't matter

What would this individual like Allies to know about them?

What kind of goals is this individual interested in accomplishing with Allies?

PLEASE READ THE REFERRAL PROCESS PAGE BEFORE COMPLETING THIS FORM!

Empowering adults experiencing intellectual and developmental disabilities by providing exceptional support services, meaningful classes, social opportunities and a safe environment to thrive.