subject_line
Aging and Disability Services
| Referral Form
Full name:
*
Age:
*
Phone number:
*
Additional phone number or videophone (VP):
Email:
Preferred contact method(s):
*
Phone call
Email
Videophone
Other:
Other:
Best Time to Contact. Select all that apply:
*
Monday
Tuesday
Wednesday
Thursday
Friday
Mornings (8:30am to 12:00pm)
Afternoons (12:00pm to 5:00pm)
Other:
Other:
Primary language:
*
English
Spanish
American Sign Language (ASL)
Vietnamese
Korean
Other
Other
City:
*
County:
*
Orange County
Los Angeles County
Other
Aging and Disability Community Partners
Which agency would you like to link this individual to? Select all that apply.
Please Note -
We recommend selecting no more than two organizations at a time as each agency will reach out to you directly. Managing multiple contacts can be overwhelming. Once you've completed services with your selected organizations, you can always return to this form to request additional assistance.
*
211 OC
- Information and Referral Services
Alzheimer's OC
- Information and referral (Dementia and Alzheimer’s related disorders), counseling and support.
Community Health Initiative of OC (CHIOC)
- Screen families for social services programs, eligibility and assisting in applying for Medi-Cal, Covered California, CalFresh, CalWorks programs and General relief.
Dayle McIntosh Center
- Independent Living Center for older adults and individuals with disabilities needing support to gain or maintain independent living.
Caregiver Resource Center OC
: (Services are for family/informal/unpaid caregivers only) – Supportive services to help with the stress and responsibilities of caregiving. Services for caregivers of someone with either an adult-onset brain impairing condition OR someone over 60 requiring daily help.
Office on Aging
- Information and referral for older adults (60+), health education workshops, senior housing search assistance (60+).
Veterans Service Office (VSO)
- Services for Veterans and individuals who are military connected.
Dayle McIntosh Center Programs and Services
Select the
primary
DMC service needed from the list below:
*
Assistive Technology
- identifying, demonstrating, and obtaining devices that can help people with disabilities live independently, including Durable Medical Equipment (DME)
Blindness/Vision Loss Services
- in-home training for individuals of all ages to adapt to living with vision loss
Community Transition Services
- coordination of tasks necessary to relocate individuals who are in nursing homes and want to move back into the community and/or assisted living facilities
Deaf Services
- daily living and self-advocacy skills in American Sign Language by and for the D/deaf, and Deaf sensitivity training for community partners
Home Modifications
- changes to the home environment that promote independence and prevent injuries and institutionalization
Housing Services
- resources and skill-building workshops to help individuals find affordable, accessible housing, and financial move-in support for Medi-Cal (CalOptima) members
Independent Living Skills
- group and individual training on daily living skills such as communication, budgeting, and cooking using adaptive techniques
Information and Referral
- information on the wide variety of programs and resources available to people with disabilities in Orange County
Peer Support Groups
- opportunities for people with disabilities to connect with each other, share experiences, and offer support
Personal Assistant Services
- helps people with disabilities find individuals to aid with personal care and housekeeping
Youth Transition
- helping young people (ages 14 to 24) prepare for adult life through group activities led by role models with disabilities
Assistive Technology
Please select needed DMC AT service(s):
*
Durable Medical Equipment (DME)
- assistance with obtaining wheelchairs, walkers, and other equipment, and accepting DME donations
Information and Referral
- information related to assistive technology including descriptions of a wide array of products, manufacturers, and resources for obtaining financial aid to acquire AT
AT Training
- basic training on the use of software such as screen readers, voice dictation, and other accessibility features on computers and cell phones
AT Demonstration
- demonstration of devices that can enhance or aid recreational, work, or activities of daily living
Select one or more:
*
Individual needs durable medical equipment (DME)
Individual would like to donate durable medical equipment (DME)
Are you a person with a disability?
*
Yes
No
What is your current annual income?
*
Are you at risk of falling, becoming injured, or losing your independence?
*
Yes
No
Select one or more that apply to the individual's home safety:
*
Worried about falls when walking
Uses a walker, cane, or other mobility aid
Fallen in past year
Hospitalized or injured due to a fall
Health condition that affects feet
Vision loss
Medications cause dizziness
Other fall risk:
Other fall risk:
Durable medical equipment (DME) needed:
*
Manual wheelchair
Power/electric wheelchair
Scooter
Shower chair
Walker
Rollator
Crutches
Cane
Hoyer lift
Hospital bed
Other:
Other:
Have you tried requesting the item(s) through your health insurance?
*
No
Yes, but I am still waiting to hear back.
Yes, but my request was denied.
I don't have health insurance.
I am not sure.
What item(s) or equipment would you like to donate?
*
DMC accepts donations of gently used working equipment (for example: wheelchairs, shower chairs, walkers, canes, and other equipment in good working order).
Items NOT accepted are wound care supplies, used commodes, and equipment in poor condition, with missing pieces or not in working order.
If you are unsure whether a donation can be accepted, contact us at (714) 621-3300.
What type of training is needed? Please name the device or technology if known.
*
Do you already have the device/software you would like training on?
*
Yes
No
Other:
Other:
Do you have a visual disability (blind, low vision, visually impaired, etc.)?
*
Yes
No
Are you 55 years or older?
*
Yes
No
Are you currently employed and/or receiving services from the Department of Rehab (DOR)?
*
Yes
No
Blindness/Vision Loss Services
Is the person 55+ years old?
*
🛈
Yes
No
Street address:
*
Zip code:
*
Type of residence:
*
Private residence (house/apartment)
Senior independent living
Assisted living facility
Nursing home
Homeless
Number of individuals in the household:
*
Cause of vision impairment:
*
Macular degeneration
Cataracts
Diabetic Retinopathy
Glaucoma
Other
Severity of vision impairment
*
Severe Visual Impairment
Legally Blind
Totally Blind with light perception
Totally Blind with no light perception
Does the individual have a secondary disability and/or chronic health condition?
*
Yes
No
Secondary disability/chronic health condition:
*
Source of referral:
*
Eye care provider
Physician/medical provider
State Vocational Rehabilitation Agency
Social Services
Department of Veterans Affairs (VA)
Senior program
Assisted living facility
Nursing home
Independent living center
Family/friend
Self-referral
Other
DMC is no longer accepting referrals for the Los Angeles area.
Please note, as of
10/1/23
the following organizations will be accepting referrals:
Blindness Support Services:
Blindness Support Services
Wayfinder Family Services:
Wayfinder Family Services
Community Transition Services
Date of Birth:
*
Are they currently living in an institution such as skilled nursing, hospital or other facility?
*
Yes
No
Name of the facility:
Admission Date (if applicable):
+
What medical insurance does the individual have?
*
Medi-Cal
Medi-Care
Medi/Medi
None
Other
Other
What is the individual's monthly income?
*
Please upload any relevant documents (admin records, face sheet, etc.)
Additional files as needed (due to size limits)
211 OC Services
Please select a 211 OC service(s):
*
Multi-service Care Coordination
CalFresh Enrollment
Medi-Cal Enrollment
Alzheimer OC's Services
Please select an Alzheimer's OC service(s):
*
Information and referral (memory loss, dementia, Alzheimer's and related disorders)
Adult day center introduction/evaluation
Advanced care/end-of-life planning
Caregiver support, counseling, and education
Dementia care planning
Early memory loss services and supports
Memory screenings, memory training, and brain health education
Safety evaluations and planning
Community Health Initiative of OC (CHIOC) Services
Please select a CHIOC service(s):
*
Information and referral (benefits specific)
CalFresh application assistance
CalWORKS application assistance
Medi-Cal application assistance
Caregiver Resource Center Services OC (CRCOC)
Check all that apply for areas of interest for CRCOC services:
*
Service Area 1: Information, Referrals, Linkage to Services (No Eligibility Requirement)
Service Area 2: Case Management/Caregiver Assessment & Long Term Care Planning (Eligibility Requirement - must be an informal/unpaid caregiver)
Service Area 3: Respite Services such as In Home Care, Out of Home Care, Assistive Technology/DME, Supplies, Cleaning Services, Legal Consultation. (Eligibility Requirement - must be an informal/unpaid caregiver)
Service Area 4: Caregiver Support Groups (No Eligibility Requirement)
Service Area 5: Individual Counseling (Eligibility Requirement - must be an informal/unpaid caregiver)
Service Area 6: Educational Classes & Training (No Eligibility Requirement)
Is the client an informal caregiver for a loved one? (Services are for unpaid/informal/family caregivers only.)
*
Yes
No
Unfortunately this referral is not eligible for Caregiver Resource Center OC's services.
If you are in need of a caregiver, please contact In Home Supportive Services (IHSS) at (714)825-3000 or select Personal Assistant Services under the Dayle McIntosh Center in the Aging and Disability Community Partners section of this referral form (above).
Office on Aging (OOA) Services
Please select an OOA service(s):
*
Information and referral (older adults)
Health education workshops
Veteran's Services Office (VSO) Services
Please select a VSO service(s):
*
Information and referral (veterans)
Benefits enrollment assistance
Veterans resource access/coordination
Deaf Services
Type of hearing loss:
*
Primary disability/diagnosis:
*
Second disability/diagnosis:
What is the individual's primary method of communication?
*
Sign language
Oral without sign language
Gestures or home signs
Pro-tactile ASL or tactile ASL
Functional limitations (if any):
Area of focus/support needed:
*
Independent living skills
Self-advocacy
Housing
DMV workshop in sign language
Deaf sensitivity training
Other:
Other:
Home Modifications
Does the individual have CalOptima insurance?
*
Yes
No
Not sure
Not sure
Currently DMC is only able to provide home modifications for CalOptima members.
For CalOptima eligibility information, please contact CalOptima at (714)246-8400.
Medi-Cal number/CIN (if known):
Are you a person with a disability?
*
Yes
No
Date of Birth:
*
What is your current annual income?
*
What type of home needs to be modified?
*
Apartment (renting)
Home (renting)
Home (own)
Condo (renting)
Condo (own)
Are you at risk of falling, becoming injured, or losing your independence?
*
Yes
No
Select one or more that apply to the individual's home safety:
*
Worried about falls when walking
Uses a walker, cane, or other mobility aid
Fallen in past year
Hospitalized or injured due to a fall
Health condition that affects feet
Vision loss
Medications cause dizziness
Other fall risk:
Other fall risk:
What type of home modification is needed? (Grab bars, ramp, etc.)
*
Housing Services
Are you in need of assistance with an eviction or housing voucher?
*
Yes
No
Please note: DMC is NOT able to assist with preventing evictions or obtaining housing vouchers.
Resources can be found at DMC's website:
Housing-Resources-updated-2023.pdf (secureserver.net)
What type of housing assistance is needed? Select one of the options below.
*
I am looking for resources for affordable, accessible housing.
I am in need of move-in assistance and/or hands-on support from a DMC Housing Coordinator.
What type of resources or information do you need support locating?
*
Are you interested in attending a housing workshop?
*
Yes
No
Which housing workshop(s) would you like to attend?
*
Housing Search and Being Document Ready: Learn how to increase your chances of successfully securing housing opportunities.
Budgeting for Housing: Learn about budgeting for housing, including how to increase your income and decrease expenses through community supports.
Housing Options: Learn about different housing options and how to apply for them.
Are you a CalOptima member?
*
Yes
No
Date of Birth:
*
CalOptima number/CIN (if known):
Have you received CalAIM housing services before?
*Please note, CalAIM housing services are only available once in a lifetime.
*
Yes
No
Are you currently experiencing homelessness or at risk of becoming homeless?
*
Yes
No
Select one or more that apply to your housing situation:
*
Homeless
Received eviction/pay or quit notice
Disability significantly impacts life
Psychiatric disability or mental illness
Substance use and/or at risk of overdose
At risk of institutionalization
Transition-age youth with significant barriers to housing stability
Receiving Enhanced Care Management (ECM)
Prioritized for services within OC Coordinated Entry System
What is your monthly income?
*
Based on the information provided, the individual is NOT eligible for DMC Housing Services at this time.
This referral will not receive a response unless another primary service is selected.
Resources for affordable, accessible housing can be found online at DMC's website:
https://daylemc.org/services/support-services/housing-assistance/
Based on the information provided, the individual is NOT eligible for DMC Housing Services at this time.
This referral will not receive a response unless another primary service is selected.
Resources for affordable, accessible housing can be found online at DMC's website:
https://daylemc.org/services/support-services/housing-assistance/
Based on the information provided, the individual is NOT eligible for DMC Housing Services at this time.
This referral will not receive a response unless another primary service is selected.
Resources for affordable, accessible housing can be found online at DMC's website:
https://daylemc.org/services/support-services/housing-assistance/
Independent Living Skills
What skill(s) does the individual want to learn? Select all that apply:
*
Basic Computer Training
Communication Skills
Community Involvement
Cooking
Laundry
Money Management
Medication Management
Organization
Time Management
Personal Safety
Self-Care
Other
Other
Information and Referral
What type of resources or information does the individual need support locating?
*
Based on the information provided, the individual is not eligible for Nursing Home to Community Transition services at this time.
Please select another service.
If so, for how long?
*
Please note: individuals must have spent at least 60 days in a skilled nursing facility (SNF) to be eligible for DMC's Nursing Home to Community Transition services.
Name of facility:
*
Admission date (if known):
Does the individual have a discharge date?
*
Is the individual a Medi-Cal (CalOptima) member?
*
Yes
No
Based on the information provided, the individual is not eligible for Nursing Home to Community Transition services at this time.
Please select another service.
Medi-Cal number/CIN (if known):
Does the individual have a reliable source of income or financial support?
*
Yes
No
Income amount:
*
Does the individual have a residence they can return to?
*
Yes
No
Date of Birth:
*
Please upload any relevant files (admin record, face sheet, etc.)
Additional files as needed (in case of size limits)
Peer Support Groups
Which peer support group(s) are you interested in?
*
Disability Chat (all disabilities)
Queer, Disabled, and Proud (all disabilities)
Low-Vision Peer Support Group
Personal Assistant Services
Address:
*
Number of authorized In-Home Supportive Services (IHSS) hours:
*
Private pay hours (if applicable):
Private pay rate:
Disability type:
*
Physical disability with mobility challenge(s)
Visual disability or blindness
Deaf or hard of hearing
Mental illness (requires supervision)
Specific disability or diagnosis:
*
What authorized services do you require from a care provider? Select all that apply.
Personal care:
Bathing/basic hygiene
Dressing
Feeding
Bladder/bowel assistance
Transfer:
Stand-by (spotting)
Hands-on (some assistance)
Total assistance (lift individual)
Domestic tasks:
Shopping/errands
Cooking and clean-up
Housekeeping
Laundry
Managing medications
Help with exercise
Take to appointments
Other
Scheduling: check the days and times of the week below that you currently require care.
Monday:
Morning
Afternoon
Evening
Overnight
Tuesday:
Morning
Afternoon
Evening
Overnight
Wednesday:
Morning
Afternoon
Evening
Overnight
Thursday:
Morning
Afternoon
Evening
Overnight
Friday:
Morning
Afternoon
Evening
Overnight
Saturday:
Morning
Afternoon
Evening
Overnight
Sunday:
Morning
Afternoon
Evening
Overnight
Specific hours needed (if applicable):
Preference:
*
Full-time
Part-time
Live-in
Weekend
Overnight
On-call
Do you prefer a non-smoker?
*
Yes
No
Additional requirements:
Do you have pets?
Dogs
Cats
Others
Others
Do you have any allergies?
*
Additional important notes (if applicable):
Youth Transition
Is the individual between the ages of 14 and 24?
*
Yes
No
Additional Programs and Services
Select any
additional
DMC services needed from the list below:
Assistive Technology
- identifying, demonstrating, and obtaining devices that can help people with disabilities live independently, including Durable Medical Equipment (DME)
Blindness/Vision Loss Services
- in-home training for individuals of all ages to adapt to living with vision loss
Community Partner Services
- direct linkage to community partner services for veterans, aging, Alzheimer's/dementia/memory loss, Medi-Cal assistance, and other information/resources
Deaf Services
- daily living and self-advocacy skills in American Sign Language by and for the D/deaf, and Deaf sensitivity training for community partners
Home Modifications
- changes to the home environment that promote independence and prevent injuries and institutionalization
Housing Services
- resources and skill-building workshops to help individuals find affordable, accessible housing, and financial move-in support for Medi-Cal (CalOptima) members
Independent Living Skills
- group and individual training on daily living skills such as communication, budgeting, and cooking using adaptive techniques
Information and Referral
- information on the wide variety of programs and resources available to people with disabilities in Orange County
Peer Support Groups
- opportunities for people with disabilities to connect with each other, share experiences, and offer support
Personal Assistant Services
- helps people with disabilities find individuals to aid with personal care and housekeeping
Youth Transition
- helping young people (ages 14 to 24) prepare for adult life through group activities led by role models with disabilities
Referral Notes
Please provide any additional relevant information about the individual's situation and needs.
Release of Information
Who are you making this referral for?
*
Myself
My friend or family member
A consumer/client
If you are making this referral on behalf of someone else, how did they consent to the release of their information?
*
Verbal Consent
Written Authorization
By my verbal affirmation, I consent to this referral and give the receiving agencies within this partnered network permission to share my information to the extent necessary to determine my eligibility for services. I understand this information will be kept confidential and will not be shared outside of the receiving agencies without my written consent.
*
Yes
No
Upload the signed release of information form below.
Referring Party Information
Name:
*
Organization:
*
Phone Number:
*
Email Address:
Thank you for your referral. The individual will be contacted per the information provided within 5 business days.
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