(Agency Name)  	Date: ____________________

SOS Intake / Referral Form 		CLIENT NAME: __________________________________________________

	Unique ID #:    ___________________________

Case Worker: _______________________		                       Congregate site  ___________________________________      Home

√	Current formal services/benefits	Info Only	Referrals	Non-Imple-mentation
Code / Date	
	Services	Date	Date of referral	Current Provider and Frequency
OR
Referral to	Imple-mentation Date 		
	Adult Day Care						
	APS/Elder Abuse Prevention						
	Chore/Companion/Homemaker						
	Congregate Meals/ Senior Centers						
	Dementia Services						
	Dental Services						
	Disaster Preparedness						
	Durable Medical Equipment						
	Emergency Assistance (utilities, food, Rx)						
	Emergency Response System						
	Employment/ Job Counseling						
	Energy Assistance (fuel, cooling, fans)						
	Eye and Ear Care						
	Financial Management/ Counseling						
	Food Stamps-Certification/Recertification						
	Friendly Visitor/Telephone Assurance						
	Health and Wellness						
	Holiday Assistance / Special Help						
	Home Delivered Meals/Supplement						
	Home Health / Therapy / Hospice						
	Home Repairs / Ramps / Yard work						
	Housing						
	Legal Assistance						
	Med Mgmt						
	Medicaid-Certification / Recert / CBC			#			
	Medical Supplies (diabetic/incontinent)						
	Medicare      (not Medicare D)			#			
	Mental Health/Mental Retardation						
	Nutrition Counseling						
	Personal Care						
	Physician Linkage						
	Rx Assistance / Medicare D / Extra Help						
	Safety at Home						
	SSA/SSI						
	Support Groups/Newsletter						
	Tax Assistance						
	Transportation						
	Veteran’s Benefits						
	Websites for Seniors						
	Other:						
	Other:						

Emergency Contact: ____________________________________________________ Relationship ______________ Phone # __________________