ADHC Referral Form (MDC)

Mt. Diablo Center for Adult Day Health Care (ADHC)

REFERRAL FORM
CLIENT INFORMATION
Client's Name*
Date of Birth*

MonthDayYear
Phone Number*
Address*
Social Security Number
Race / Ethnicity*

CaucasianHispanic / LatinoBlack / African AmericanNative American / American Indian / Indigenous / Alaska NativeAsianNative Hawaiian / Pacific IslanderOtherUnknownPrefer Not to Say
Preferred Language*

EnglishFarsi / DariRussianSpanishOther
Limited English Proficiency?*

YesNo
Current Living Situation*

Board & CareLives AloneLives with FamilyLives with CaregiverOther
Sex at Birth*

MaleFemaleIntersexPrefer Not to Say
Gender*

MaleFemaleNon-binaryGender QueerTrans MaleTrans FemalePrefer Not to SayOther
Sexual Identity*

Straight / HeterosexualBisexualLesbianGayQueerPrefer Not to SayOther
REFERRAL INFORMATION
Contact Person*
Relationship to Client*
Email Address*
Phone Number*
Referred By*
Reason for Referral*
Risk Urgency Level*

HighModerateLow
Reason for Urgency Level*
Is the client aware of this referral?*

YesNo
Do you wish to remain anonymous?*

YesNo
Doctor's Name*
Phone Number*
Diagnoses*
Special Concerns*
Ambulation*

SelfWalkerWith AssistanceCaneWheelchairOther
ACTIVITIES OF DAILY LIVING

Rating Scale:

1 - Independent
2 - Verbal Assistance
3 - Some Human Help
4 - Lots of Human Help
5 - Dependent
6 - Decline to State
Slide to rate the client's functional abilities for the following ADLs:
INSTRUMENTAL ACTIVITIES OF DAILY LIVING

Rating Scale:

1 - Independent
2 - Verbal Assistance
3 - Some Human Help
4 - Lots of Human Help
5 - Dependent
6 - Decline to State
Slide to rate the client's functional abilities for the following IADLs:
Notes
Diet*

RegularLow SaltSoftDiabeticOther
Problems with Swallowing?*

YesNo
Financial Coverage*

CCHPBlue CrossVARCEBPVTScholarship RequestedOther
Below Federal Poverty Level?*

YesNo
Medi-Cal?*

YesNo
Medi-Cal #*
Medi-Cal Issue Date*

MonthDayYear
Transportation*

PVTCounty LineTri Delta TransitOther
Enrolled in Silver Ride?*

YesNo
Call (925) 938-7433 or (925) 676-7500 to enroll.
Psychiatric Diagnosis?*

YesNo
Explain*
Psychiatric Provider?*

YesNo
Name of Provider*
Has the client had a TB test within the last year?*

YesNo
Is there anything else we should know?
How did you hear about us?
Should be Empty:

Mt. Diablo Center for Adult Day Health Care (ADHC)