Referrals

Consent

Client or Client Representative consents to this Referral *

Date *

Client (person needing assistance) Information

Client's Name (person needing assistance) *

Phone *

Email Address *

Date of Birth *

RID # / Medicaid #. *

Address *

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Preferred Point of Contact (if not client)

Name of preferred point of Contact *

Relationship to client *

Family
Friend
Relatives
Any other

Please Write Here

Phone (of preferred point of contact)

Email (of preferred point of contact) *

Referring Person's Information

Referral source name *

(agency, family, friend)

Referring Person's source phone *

Referral source Email *

Disclaimer: *

Signature

Client Signature *

Client Electronic Signature *

For Electronic Signature: Please use Mouse, Touchpad, Stylish Pen or Your finger:

Signature Date *

Electronic Signature Disclaimer

Please ensure all information is correct before hitting Submit, as this is a Legal Document, and may be used in legal proceedings. Your signature is made with intent, and by signing your name electronically to this Referral Form (Structured Family Home Care), you are agreeing that your signature is the legal equivalent of your manual signature. If you want to opt out of the online Referral Form (Structured Family Home Care), or any other online form, please contact the office and paper forms will be sent to you.

Have You read the Electronic Signature Disclaimer above: *

Comment