Referral form

Address *

Phone Number *
Social Security Number *
Date of Birth *

Month Day Year
Date
Living Situation

Alone With Parent(s) Spouse Children Friends
Primary Insurance Information
Insurance Information

Medicaid Medicare Amerigroup CareSource PeachState WellCare Private Insurance
Insured Identification Number

Insurance Address

Does the individual have a secondary insurance?

Yes No
Secondary Insurance Information

Skip section if not applicable
Insurance Information

Medicaid Medicare Amerigroup CareSource PeachState WellCare Private Insurance
Insured Identification Number

Insurance Address

Diagnosis Information
Primary Diagnosis *
Secondary Diagnosis
Other Medical Diagnoses
Referring Agency Information
Agency Name *
Referral Staff Name *

First Name Last Name
Referring Agency Admission Date (date individual came to your agency)

Month Day Year
Date

Address

Rate living skills in the following areas

Doesn't Need Assistance

Needs Some Assistance

Needs Ongoing Assistance

Housekeeping

Food Prep/Storage

Grocery Shopping

Transportation

Communication
(use phone, make appointments)

Leisure time planning

Money Management

Ability to Arrange Healthcare

Interpersonal Skills

Referral for Lookout Mountain Community Services IDD Program