Caredove

Service:

CR - SDL
Organization: Central Registry > Nucleus Independent Living
Description:

Provides assistance in connecting clients with a variety of services from local community agencies. Services include in-home personal support and homemaking services.

Referral Options:

Is the client cognitively competent to direct their own care?

Does anyone besides the client need to be present during assessment?

Client requires translation.

Is the client in need of a new residence in addition to support?

Does the client currently reside in an SDL building or surrounding hub area?

What Support Activities are Required Throughout a 24hr Period?

Personal Hygiene:

Morning Visit

Afternoon Visit

Evening Visit

Overnight Visit

Toileting:

Morning Visit

Afternoon Visit

Evening Visit

Overnight Visit

Transferring/Turning:

Morning Visit

Afternoon Visit

Evening Visit

Overnight Visit

Dressing/Undressing:

Morning Visit

Afternoon Visit

Evening Visit

Overnight visit

Preparing Meals/Assistance with Eating:

Morning Visit

Afternoon Visit

Evening Visit

Overnight Visit

Medication Reminders:

Morning Visit

Afternoon Visit

Evening Visit

Overnight Visit

Safety Check:

Morning Visit

Afternoon Visit

Evening Visit

Overnight Visit

Exercise/Range of Motion:

Morning Visit

Afternoon Visit

Evening Visit

Overnight Visit

Essential Light Housekeeping:

Morning Visit

Afternoon Visit

Evening Visit

Overnight Visit

Does client consent to Meals Program referral?

If yes, what Meals resources are required?

Information about meals

Meals delivered to the home

Resources to access food

Congregate Dining

Where is the client currently located:*

This field is required

Referral Source Location:*

This field is required

Referral source extension:

Eligibility:*

Client Name:*

First name*

This field is required

Family/Last Name*

This field is required

Personal Pronouns:

This field is required

Email Address:

Email (Confirmation and reminder emails will be sent here)

This field is required

Phone:

Primary Phone*

This field is required

Secondary Phone

This field is required

Address:

Unit/Suite #

This field is required

Street # & Street Name*

This field is required

City*

This field is required

Postal/Zip Code*

This field is required

Gender:

Male

Female

Undisclosed/Other

This field is required

Date of Birth:*

Day

Month

Year

This field is required

Ineligible - You have specified age of .

The age eligibility requirements for this service is:

Warning: Submission may be denied.

Client Health Card Number:*

Client Health Card Number*

This field is required

Version Code*

This field is required

Living Arrangements:

Alone

with Spouse/Partner

with Family/Caregiver

Other

This field is required

Family Doctor:

Family Doctor Name

This field is required

Family Doctor Phone #

This field is required

Conduct Appointment With:

Client

Referral Source

Power of Attorney

Alternate Contact (if anyone besides the client need to be present during assessment)

This field is required

Referral Source Name:

First name

This field is required

Family/Last Name

This field is required

Referral Source Email Address:

This field is required

Referral Source Info:

Primary Phone

This field is required

Secondary Phone

This field is required

Relationship to Client:

Spouse

Son/Daughter

Sibling

Parent

Friend

Legal Guardian

Other

This field is required

Power of Attorney Name:

First name

This field is required

Family/Last Name

This field is required

Power of AttorneyEmail Address:

This field is required

Power of Attorney Info:

Primary Phone

This field is required

Relationship to Client:

Spouse

Son/Daughter

Sibling

Parent

Friend

Legal Guardian

Other

This field is required

Alternate Contact (if anyone besides the client need to be present during assessment) Name:

First name

This field is required

Family/Last Name

This field is required

Alternate Contact (if anyone besides the client need to be present during assessment) Info:

Primary Phone

This field is required

Reason for Referral:

Surgery

- Specify Date of Surgery:

This field is required

Acute Event

- Specify Date of Event:

This field is required

Worsening of a Chronic Condition

- Specify Start Date of Worsening:

This field is required

Hospital Discharge

- Specify Date of Discharge:

This field is required

Other

- Specify Date:

This field is required

(Please specify date above if known.)

e.g., New diagnosis, reason for recent hospital admission, caregiver burnout, prior to hospitalization who was the patient serviced by,
Floor and Room Number (if client is being discharged from hospital)

This field is required

Related Hospital Visit:

Recent Discharge

Currently Admitted

Emergency Department

This field is required

Hospital

This field is required

Allergies:

Please list and describe any allergies

This field is required

Medications:

List all medication, and dosages per day

This field is required

Risk Factors:

AccessCSS and our service partners offer a wide range of community support services for older adults.

Other

This field is required

Complete if client requires translation:

List Name, Phone, and Relationship of translator.:

Documentation:

Send additional documentation online through Caredove, or separately via other methods (e.g., fax)

Add files

Notifications:

Send confirmation, change & reminder messages to < name> < email>

Yes

Name:*

This field is required

Name:*

This field is required

Service Information

What Support Activities are Required Throughout a 24hr Period?

Client Information

Submission complete

Summary