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Mission
Applications
- DSP Application
- Client Referral Application
Contact

— Client Referral Application —

Step 1: ABOUT THE CLIENT

Client Full Name*

Birthdate*

Client Address*

Primary Contact Phone*

Guardian, client, or emergency contact

Primary Contact Email*

Preferred Contact Method*

Communication Notes

Step 2: CASE MANAGER & GUARDIAN INFO

CASE MANAGER / PERSONAL AGENT

CM/PA Name

CM/PA Phone

CM/PA Email

Case Management Entity

GUARDIAN / CONSERVATOR

Guardian Name

Relationship to Client

Guardian Phone

Guardian Email

Guardian Preferred Contact Method

Legal Notes

Section 3: SUPPORT NEEDS (Medical + Behavioral)

Medical Needs

Behavioral Needs

Supervision Level

Relevant Risk Flags

Elopement / wandering risk

Aggression toward self

Aggression toward others

Complex medical needs

Feeding protocols

High fall risk

Incontinence care

Nonverbal / uses AAC

Court involvement

History of provider turnover

Other

Upload Documentation

Note: Please submit confidential or sensitive documentation via encrypted email to referrals@healthylifeservices.org

Step 4: SCHEDULING & PRIMARY GOALS

Support Start Timeframe

Current Gap in Care

Yes

No

Unsure

Availability (Weekdays)

Weekday mornings

Weekday afternoons

Weekday evenings

Availability (Weekends)

Weekend mornings

Weekend afternoons

Weekend evenings

Ideal Weekly Schedule

Transportation Needs

PRIMARY GOALS

Primary Care Goals

Additional Notes

Step 5: SUBMITTER INFO & CONSENT

Your Full Name*

Your Relationship to the Client

Your Phone

Your Email*

I confirm the information provided is accurate and give Healthy Life Services permission to contact me and the people listed so we can begin the referral process.

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