VOLUNTEERS OF AMERICA OREGON
Adult Day Services Referral Form
Referral Source:
☐VA
☐H
ospital Discharge Planner
☐Adult Care Home
☐OPI
☐LAMBERT HOUSE EAST (MID/EAST COUNTY)
Phone: (503)760-2075 Fax: (503)760-2192
☐SUNDANCE
Phone: (503)760-2075 Fax: (503)760-2192
☐MARIE SMITH CENTER (N/NE/NW PORTLAND)
Phone: (503)335-9980 Fax: (503)335-0993
☐ADVS/Medicaid
☐State -OR- ☐Brokerage
☐Private Case Manager
☐Providence ElderPlace
☐Other:
Zip:
Sex/Gender:
Client Information
Name:
Address:
City:
Home Phone:
DOB:
Marital Status:
Religious Preference:
Ethnicity:
Diagnosis:
☐Cognitive Impairment ☐Stroke ☐Diabetes
☐Musculoskeletal Disorder ☐Depression
☐Emotional Health
Reason for Requesting Services:
☐Other: ☐Respite ☐Working Caregiver ☐Behavioral Expressions
Spec
ial Diet:
Allergies:
Funct
ional Needs:
☐Wheelchair ☐Walker ☐Cane ☐Quad Cane
☐Glasses ☐Hearing Aide(s)
Primary Physician:
Hospital Preference:
☐Healthcare Issues ☐Other:
Caregiver/Primary Contact Information:
Name:
Relation to client:
Address:
City: Zip:
Home Phone #:
Work/Cell Phone #:
Email:
Transportation:
☐Tri-Met Lift ☐Caregiver
☐Ride to Care ☐R
ide Con
nection
You may also fill out a referral form online at www.voaor.org
Billing Information: Please sign and authorize!
Max. Days Authorized: ☐per week ☐per month
-OR-
Max. Hours Authorized: ☐per week ☐per month
Name of person authorizing:
Billing Address:
ADVS branch/OPI branch -OR- Brokerage Firm:
OPI/Medicaid #:
Case Manager:
Phone #:
*Tour: ________ *Intake________
*First Day: _______ *Days Attending: _____
