Referrals -

Client Information

Client Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Client Phone (if applicable)

Diagnosis

Other Services:

Guardian:No: Emancipated AdultYes: Enter guardian information below

Guardian & Case Manager Information

Guardian Name

Guardian Phone

Case Manager Name

Case Manager Phone

Living Arrangements

Please select living arrangements that client is requesting:Shared housing w/24 hour supportsLiving alone with 24 hour supportsLiving alone with 24 hour supports that includes PA servicesLiving alone with less than 24-hour staffing supportsLiving in Family home

Hours Clients Is Needing

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Medical EquipmentsNoYes; Please describe below

Communication:Verbal—Communicates all wants and needs without any problemVerbal—has problems communicating wants and needsNon-verbal—CAN communicate wants and needs Non-verbal—DOES NOT communicate wants/needs

Please provide additional information regarding the level of clients communication abilities

Please provide any additional relevant information regarding clients mobility

Self Care

No assistance needed (able to complete all task with no assistance)

Needs verbal prompts to:

Select

Brush TeethToiletingShower

Needs assistance with:

Select

Brush TeethToiletingShower

Wears depends/diapers

Cooking:

Independent

Needs help to cook meals

Select

Needs verbal promptsNeeds assistance

Staff cook all meals

Cleaning:

Independent

Needs help to clean

Select

Needs verbal promptsNeeds assistance

Staff will need to do all the cleaning

Behavioral Information

Does client have a Behavioral Clinican?NoYes: Enter clinician information below

Clinician Name

Clinician Email

Clinician Phone

Dietary

RestrictionsNo diet restrictionsDiet restrictions; Describe below

Description of dietary restrictions

AllergiesNoYes; Describe allergies below

Description of allergies

Required DocumentsSix (6) months of BDDS reportsBehavioral Support PlanD&E or functional AnalysisHigh Risk PlansPlease upload copies of documents below

Please upload any of the reports checked off above or any other relevant documentation

Other Information:

CISS would love the opportunity to work with your family member or client. Please fill out the form below and someone will be in contact with you soon.

Client Information

Guardian & Case Manager Information

Living Arrangements

Hours Clients Is Needing

Self Care

Cooking:

Cleaning:

Behavioral Information

Dietary