Follow the steps to successfully complete the form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the IHSS applicant section. Provide your last name, first name, middle initial, street address, apartment number (if applicable), zip code, social security number, birth date, phone number, and email address. Ensure all information is printed clearly.
3. Indicate your gender identity by selecting the option that best describes you from the provided choices. Additionally, specify your sex at birth.
4. Describe your sexual orientation or identity by selecting the appropriate option. If none apply, you can specify your preference.
5. Fill in your ethnicity and any languages you speak.
6. Answer the questions regarding whether you receive Supplement Security Income (SSI) and if you are enrolled in Medi-Cal.
7. In the referent information section, provide the referent's name, phone number, relationship to you, and any associated agency or organization.
8. Complete the residence/discharge information section by detailing your living situation, whether you live alone, the relationships of household members, and your current status (at home or hospitalized). Include discharge details if applicable.
9. If you are married, provide information about your spouse, including their name, social security number, and whether they receive IHSS. Answer questions about their ability to do housework and provide their doctor’s information.
10. Indicate whether emergency on-call home care is requested and explain why services are necessary.
11. Fill out the applicant’s physician/clinic information by providing the name, specialty, address, and contact details.
12. Describe any medical or mental health conditions and include any additional comments that might assist in your application.
13. Provide emergency contact information for two individuals.
14. Assess your functional abilities by selecting the level of assistance needed for various daily activities.
15. Indicate any risks and provide details on any past or current behaviors or issues.
16. Outline how your current service needs are being met and list any services you currently receive.
17. Express interest in additional services such as On Lok Lifeways or adult day health care programs.
18. After completing all sections, review your form for completeness, then save your changes. You can download, print, or share the form as needed.

Start completing your CA IHSS 3012 form online today!