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: *

Primary language: *

City: *

County: *

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.

Mint Health Solutions - Healthcare organization that focuses on case management and service referrals available through the Linkages Program, as well as Home Health Coordination and Telehealth Medical Services.

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: *

Mobility Management Professionals Program (MMPP) - Coming Soon! Please check back for more information on submitting a referral after 3/1/25.

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: *

Have you tried requesting the item(s) through your health insurance? *

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: *

Number of individuals in the household: *

Cause of vision impairment: *

Severity of vision impairment *

Does the individual have a secondary disability and/or chronic health condition? *

Yes

No

Secondary disability/chronic health condition: *

Source of referral: *

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? *

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.) *

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

Mint Health Solutions

Please select a Mint Health Solutions service(s): *

Linkages Program - Provides case management and service linkage referrals to promote independent living and delay placement in nursing facilities.

Home Health Coordination - Experienced medical providers certify and oversee your home health enrollment, ensuring access to high-quality skilled nursing, physical therapy, and other services designed to enhance independence and ensure comprehensive support in the comfort of your home.

Telehealth Medical Evaluation - Consultations with a medical provider via virtual video visit. Our services include prescription refills, minor non-emergent medical concerns, ordering lab or imaging referrals, health education and more.

To help determine program eligibility for the Linkages Program, select only one of the following statements if it applies to you. *

Older Adult (Age 60+)

Functionally-Impaired Adult (Age 18+)

Neither statement applies to me

Functionally-Impaired Adult (Age 18+) defined as one that meets 1 of the following circumstances:

Impairment with completing 1 or more Activities of Daily Living (ADLs): (bathing, toileting, dressing, eating, breathing, and transferring/mobility)
Impairment with completing 2 or more Instrumental Activities of Daily Living (managing finances, transportation, meal preparations, home maintenance, medications, communication OR Cannot manage one's own affairs due to cognitive or emotional impairment

Unfortunately, this referral is not eligible for the Linkages Program. Please reach out to 211 or findhelp.org for additional resources.

Please select the area(s) you need assistance. Select all that apply to the Linkages Program: *

Please note, Mint Health Solutions does not provide emergency housing crisis assistance services, emergency medical services or emergency mental health crisis services.

To help determine program eligibility for Home Health Coordination, please select your health insurance: *

Unfortunately, this referral is not eligible for the Home Health Coordination Program. Please reach out to 211, findhelp.org or your health insurance plan for additional resources.

To help determine program eligibility for Telehealth Medical Evaluation, please select your health insurance: *

Unfortunately, this referral is not eligible for the Telehealth Medical Evaluation Program. Please reach out to 211, findhelp.org or your health insurance plan for additional resources

Deaf Services

Type of hearing loss: *

Primary disability/diagnosis: *

Second disability/diagnosis:

What is the individual's primary method of communication? *

Functional limitations (if any):

Area of focus/support needed: *

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? *

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: *

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:

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: *

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:

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.