Get Referral Form - Community Action Partnership Of North Alabama

Filling out the Referral Form for the Community Action Partnership Of North Alabama is an important process designed to connect individuals with essential resources. This guide provides clear and straightforward instructions to help you complete the form effectively and ensure that it meets your needs.

Follow the steps to fill out the form accurately and efficiently.

1. Press the ‘Get Form’ button to obtain the form and access it in your preferred editor.
2. Begin by entering the date at the top of the form. This helps to establish a timeline for the referral.
3. In the section labeled 'Client’s/Patient’s Name,' input the full name of the individual requiring assistance and provide their phone number.
4. Complete the address fields, including street, city, state, and zip code, to ensure accurate reach.
5. In the 'Directions to Home' section, provide specific instructions that may help volunteers find the client's residence easily.
6. Fill in the birth date of the client/patient to assist in proper identification.
7. Select the client’s gender by marking the appropriate box.
8. Identify the ethnic group by checking the applicable box, ensuring inclusivity in the application.
9. Indicate living arrangements by selecting the option that best describes the client's situation.
10. If applicable, answer yes or no regarding the client’s status as a veteran or the widow of a veteran.
11. In the 'Pets in the Home' section, indicate whether there are any pets present, and the same for smokers.
12. Check the Medicaid waiver option accordingly and enter the client's monthly income.
13. List at least two emergency contacts, including their names, addresses, and telephone numbers.
14. Provide the details of the physician involved with the client, including name, address, and contact number.
15. Specify the preferred schedule and hours for the assigned volunteer to maximize assistance.
16. On the back of the form, detail the client's specific needs, the volunteer's expected activities, accomplishments, and the anticipated impact of these actions.
17. Ensure to include authorized signatures to finalize the agreement. Each party involved should sign, including the client or their legal representative, the Senior Companion Volunteer, and the Volunteer Station Representative.
18. Once all sections are completed, review the form for accuracy, then save your changes, download or print the completed form for submission.

Start filling out the referral form online today to connect individuals with the support they need.