Professional Referral

Requesting Professional's Information

Your Name:*

First Last

Organization:*

Phone:*

Email:*

Enter Email Confirm Email

Patient / Client #1 Information

Please fill in patient/client's name and address if the patient/client can be contacted directly. If they have a caregiver who speaks on their behalf, please fill in BOTH the client/patient name and the caregiver's name and provide the CAREGIVER'S phone number.

Client/Patient #1 Name:*

First Last

Caregiver Name:*

Use this field if the patient/client has someone who speaks on their behalf.

First Last

Client/Patient #1 Address:*

*

Contact #1 Phone:*

Please enter number of either the client/patient OR their caregiver who speaks for them.

Patient / Client #2 Information

Please fill in patient/client's name and address if the patient/client can be contacted directly. If they have a caregiver who speaks on their behalf, please fill in BOTH the client/patient name and the caregiver's name and provide the CAREGIVER'S phone number.

Client/Patient #2 Name:*

First Last

Caregiver Name:*

Use this field if the patient/client has someone who speaks on their behalf.

First Last

Client/Patient #2 Address:*

*

Contact #2 Phone:*

Please enter number of either the client/patient OR their caregiver who speaks for them.

Requested Services

*

YES - the Patient/Client(s) has (have) authorized release of personal information only to Benevilla. This information will remain confidential and be used only to help patient/client(s) obtain information and/or services. If contacting the caregiver, the patient/client has authorized the caregiver to speak for them.

Yes

Services needed (check all that apply)*

Life Enrichment Programs–Members join in activities that challenge them to stay physically, socially, and mentally active.
Transportation to Medical Appointments–Volunteer helps a person maintain their independence and dignity by taking them to and from medical, dental, and other appointments.
Phone Pal–Trained volunteer will make regular phone check-ins with patient/client providing socialization. Will alert Benevilla I&R staff of obvious health/wellness changes.
Service Coordinator–Volunteer trained and supervised by Benevilla I&R Department. Provides in-home assessment, prepares and implements the care plan, and provides follow up services to enable patients/clients to remain independent in their own home.
Meals on Wheels–Healthy, freshly prepared meals delivered direct to the patient/client's home. Meals available 3 to 7 days a week, delivered at lunchtime.
Errands–Available for emergency support (pick up non-narcotic prescriptions, etc.)
Support Groups–Support for family members who are caregivers. Free respite care for patient may be available.

Other: describe

Follow Up

Please contact me to follow up on this referral*

Phone
Email