DAYLE MCINTOSH CENTER | Referral Form

Preferred contact method(s): *
 
Primary language: *
 

Programs and Services

Select the primary service needed from the list below: *
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): *
Select one or more: *
Are you a person with a disability? *
Are you at risk of falling, becoming injured, or losing your independence? *
Select one or more that apply to the individual's home safety: *
 
Durable medical equipment (DME) needed: *
 
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.

Blindness/Vision Loss Services

Is the person 55+ years old? * 🛈
Does the individual have a secondary disability and/or chronic health condition? *
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: *
Alzheimer's OC services: *
Community Health Initiative of OC (CHIOC) services *
Office on Aging services: *
Veterans Service Office services: *

Deaf Services

Area of focus/support needed: *
 

Home Modifications

Does the individual have medical insurance? *
 
Are you a person with a disability? *
What type of home needs to be modified? *
Are you at risk of falling, becoming injured, or losing your independence? *
Select one or more that apply to the individual's home safety: *
 

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)
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. *
Are you interested in attending a housing workshop? *
Which housing workshop(s) would you like to attend? *
Are you a CalOptima member? *
Have you received CalAIM housing services before? *Please note, CalAIM housing services are only available once in a lifetime. *
Are you currently experiencing homelessness or at risk of becoming homeless? *
Select one or more that apply to your housing situation: *
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

Based on the information provided, the individual is not eligible for Nursing Home to Community Transition services at this time. Please select another service.
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.
Is the individual a Medi-Cal (CalOptima) member? *
Based on the information provided, the individual is not eligible for Nursing Home to Community Transition services at this time. Please select another service.
Does the individual have a reliable source of income or financial support? *
Does the individual have a residence they can return to? *


Peer Support Groups

Which peer support group(s) are you interested in? *

Personal Assistant Services

Disability type: *
What authorized services do you require from a care provider? Select all that apply.
Personal care:
Transfer:
Domestic tasks:
Scheduling: check the days and times of the week below that you currently require care.
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
Preference: *
Do you prefer a non-smoker? *
Do you have pets?
 

Youth Transition

Is the individual between the ages of 14 and 24? *

Additional Programs and Services

Select any additional services needed from the list below:

Referral Notes

Release of Information

Who are you making this referral for? *
If you are making this referral on behalf of someone else, how did they consent to the release of their information? *
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. *

Referring Party Information

Thank you for your referral. The individual will be contacted per the information provided within 5 business days.
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