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
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.