North Shore Elder Services Behavioral Health Referral Form

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Date of Birth*
Can messages be left on this number?*
Medicare #:*
Who lives in the home:*
Animals in the home:*
Any infestations known including bed bugs, rodents, etc.*
Any weapons in the home? If so, are they secured?*
Any parking restrictions or recommendations?*
Any risk to the therapist entering the home?*
What in-home services are being received, if any?*
Any notable medical issues or physical limitations?*
Brief description of why the client requires behavioral health services:*
Cognitive Deficits:*
Any known substance use issues?*
Referral source:
Name*
First Last
Phone*
Agency/Title (if applicable):*
Is the elder aware of the referral?*
Initial phone call will be made by behavioral health therapist to further determine need and eligibility.