Basic Waiver Referral Form

First Name

Last Name

Phone Number

Birthday

Month

Day

Year

Address

Diagnosis Code

PMI

Referral Information

Name

Phone Number

Services in need

24-hour emergency assistance: On-call counseling and problem-solving and/or immediate

Companion services: Non-medical care, supervision and socialization to a person age 18 or older.

Homemaker services: Eligible services range from light household cleaning to household cleaning with incidental assistance with home management and/or activities of daily living.

Individualized home supports without training: Services for adults or children when they need support, assistance and supervision in at least one of the community living service categories when living in their own home or family home. Community living service categories include community participation; health, safety and wellness; household management; adaptive skills

Night supervision: Provides overnight assistance and monitoring by staff in the person's own home.

Respite care services: Short-term care due to the absence or need for relief of the family member(s) or primary caregiver normally providing the care.