DAYLE MCINTOSH CENTER | Referral Form

Full name: *

Date of birth: *

Phone number: *

Additional phone number or videophone (VP):

Email:

Preferred contact method(s): *

Primary language: *

City: *

County: *

Programs and Services

Select the primary 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 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

Please note: DMC is not currently accepting Nursing Home to Community Transition referrals due to limited staff capacity.

Assistive Technology

Please select needed 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 Partner Services

Which agency would you like to link this individual to? *

211 OC services: *

Multi-service Care Coordination

Alzheimer's OC services: *

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 *

Information and referral (benefits specific)

CalFresh application assistance

CalWORKS application assistance

Medi-Cal application assistance

Office on Aging services: *

Information and referral (older adults)

Health education workshops

Veterans Service Office services: *

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? *

Functional limitations (if any):

Area of focus/support needed: *

Home Modifications

Does the individual have medical insurance? *

Medi-Cal number/CIN (if known):

Are you a person with a disability? *

Yes

No

What is your age? *

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

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

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

What is the individual's age? *

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 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 Dayle McIntosh Center (DMC) 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 DMC 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.