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REFERRAL

Referral Form

LifeStream accepts referrals for service in the following counties: Blackford, Delaware, Fayette, Franklin, Grant, Henry, Jay, Madison, Randolph, Rush, Union, Wayne.

Click here to access the PDF version of the referral form.

Name of individual filling out this form:(Required)

First Last

Are you making a clinical or professional referral?(Required)

Yes

No

Are you making a referral for a D-SNP participant?(Required)

Yes

No

Are you making a referral for Dementia Care Support?(Required)

Yes

No

D-SNP Care Manager's Name(Required)

First and Last Name

D-SNP Care Manager's Email Address(Required)

Please select the D-SNP Provider from the dropdown list.(Required)

Consent

I give permission for my clinical provider to give my name, address, phone number, and the client information below to LifeStream Services so that a phone options counselor from LifeStream may contact me or my personal representative about options that are available to me and my family. I understand that LifeStream may provide feedback to my clinical provider based on our contact.*

Client/Client Representative consent to this referral

Date(Required)

MM slash DD slash YYYY

Individual's Name (person needing assistance)(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email

Preferred Contact Person (if not individual needing services)

First Last

Relationship to referred individual

Phone number for preferred contact

Email for preferred contact

Primary disability type or diagnosis(Required)

Is this individual currently in a nursing facility or rehab center?(Required)

Yes

No

Is this individual currently admitted to the hospital?(Required)

Yes

No

Name of nursing facility, hospital, or rehab center in which the individual is currently admitted:(Required)

Identify client needs, check all that apply (one checkmark is required to submit)(Required)

General information about long term services and support

Assistance with personal care (such as bathing, dressing, toileting, etc.)

Caregiver support/respite

Emergency response alert buttons

Home modifications/ repairs/ accessibility

Housing (independent, assisted living, nursing facilities)

Meals (home-delivered, meals sites, meal prep)

Medical supplies or equipment (ex. adult diapers)

Medicare or Medicaid counseling

Public benefits application assistance (ex. SNAP)

Transportation

Other

If you chose 'other,' please describe:

Professional or Clinical Referrals

If applicable.

Referral Source Name(Required)

Agency/Clinic Name(Required)

Professional or Clinical Referral Number

Professional or Clinical Referral Email(Required)

Disclaimer(Required)

The individual must agree to any assessment for services. If the individual cannot be reached due to incorrect information referral will not be complete.

I agree to the policy.

Individual's First and Last Name (this will be used as your signature)(Required)

First Last

Date(Required)

MM slash DD slash YYYY

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