VENTURA COUNTY AREA AGENCY ON AGING

ELDERHELP PROGRAM (EHP) REFERRAL FORM 2012-2013

Please e-mail this form to or fax to 805-477-7312 (emails preferred)

REQUESTING AGENCY INFO
Requesting Agency: / Today’s Date:
Requestor: / Phone Number:
Email Address or Fax #: of Requestor:
PLEASE SELECT ONEEHP SERVICE
1. Chore(Deep Cleaning) / 2.Homemaker(Light Cleaning) / 3.Personal Care(Bathing)
4.Minor Home Repair/Modification and/or Security Devices
  • What is needed?
  • Does client own their home? Yes No
If no, has landlord been contacted re: these needs? Yes No
5.Senior Life Boat - Emergency Aid Vouchers: By selecting this checkbox, I certifythe need for a Senior Life Boat - Emergency Aid Voucher and if approved,agree to be the responsible party coordinatingvoucher assistance.
  • Describe situation & specific assistance needed:
  • Can your agency share in the cost? Yes No
  • Have other agencies been called prior to this referral? Yes No
  • Comments:
A.Emergency Food/Grocery Store Voucher(voucher for nutritious food staples; no alcohol/cigarettes)
B.Money Management Voucher(voucher for foreclosure assistance, tax forms, money management, etc.)
C.Homeless Prevention Moving Voucher(voucher for one truck/haul; client’s items only; moving company will call referring senior service agency to schedule)
  • Address client moving to:
  • Estimated move date:
D. Homeless Prevention Rental Deposit Voucher(OTO limited funds)
  • Property Management and/or Owner Name and Phone #:
  • Deposit amount needed:
  • Date needed:

MARK ONE BOX BEST DESCRIBING CLIENTS OVERALL SITUATION
Relatively Stable
has some family support / Early Deteriorating
self determined, aware of risks / Actual/Potential Crisis
recent hospital discharge and/or lives alone
CAREGIVER INFO (IF APPLICABLE)
Caregiver/Alternate Contact Name:
Phone Number for Caregiver/Alternate Contact:
REQUIRED INFO ABOUT THE CLIENT
Client Name: / Phone Number of Client:
Street Address Where Care Is To Be Provided From:
City: / Zip Code:
Date of Birth: (must be age 60+) / Primary Language:
Gender : Male Female Other / Marital Status:
Does client live alone? Yes No
Does client have hoarding issues? Yes No
Any known firearms, animals, etc.? Yes No
Additional Comments/Concerns: / Annual Income Level:
Single
Below $11,170
(at or below 100% FPL)
$11,171 or more
Declined tostate / Married
Below $15,130
(at or below 100% FPL)
$15,131 or more
Declined tostate
Ethnicity:
Hispanic/Latino / Not Hispanic/Latino
Race (Choose One):
White
American Indian or
Alaska Native
Chinese
Japanese
Filipino
Korean / Vietnamese
Asian Indian
Laotian
Cambodian
Other Asian
Black or African American
Guamanian / Hawaiian
Samoan
Other Pacific Islander
Other Race (includes Hispanic/Latino)
Multiple Race
Declined to State
Daily Activities –
Help Is Needed: / Independent,
Needs No Help / Verbal Cueing Required / Standby Assistance
Required / Hands On Assistance Required / Dependent On Others For The Task
Eating/Feeding Self
Dressing
Transferring
Bathing
Toileting
Grooming
Walking
Preparing Meals
Shopping
Managing Medicines
Managing Money
Using the Telephone
Doing Heavy Housework
Doing Light Housework
Using Avail Transportation
FOR VCAAA USE ONLY
Date EHP Referral Received: / Approved: Yes No
Date Requesting Agency Contacted: / Comments:
Approved Service: Personal Care Homemaker Chore Senior Life Boat Emergency Aid
Home Mod &/or Sec Devices (Ownership: ) Personal Affairs Asst Other:
Units approved: / Service Date(s) Approved:
Price per Unit: / Vendor Selected:

08/2012