Referral for Services - The Arc of East Central Iowa

Instructions

The Arc requires completion of ALL of the following information for individuals requesting consideration for Arc services. The information provided will be kept confidential in accordance with Federal and State Confidentiality Laws and HIPPA requirements.

Submitter's Name *

Submitter's Email *

Referral Information

Individual's Legal Name *

Marital Status *

Goes by

Birthdate *

Age *

Social Security Number

Gender *

Street Address *

Country

City

State

Zip code

Home Phone *

Cell Phone

Email *

Race *

Please provide race: *

Ethnicity *

Employment Status *

Primary Language *

Please provide language *

County *

Please provide county *

Diagnosis *

Diagnosis Code

Diagnosis 2

Diagnosis 2 Code

Diagnosis 3

Diagnosis 3 Code

Diagnosis 4

Diagnosis 4 Code

Medical Conditions *

Is this individual registered as a sex offender? *

Yes

Has this individual been registered as a sex offender in the past? *

Yes

If other, please describe/specify: *

Please comment/describe any history of violence or aggression:

Current Legal/Charges (Voluntary/Involuntary/Guardian/History)

Referred by:

Referred by Name *

Agency

Phone *

Email *

Reason for Referral *

Medicaid Number

Services are requested for:

Adult

Child

MCO

Iowa Total Care

Wellpoint

Other

If other, please provide MCO

Member #

Funding Source

HCBS/ID Waiver

HCBS/H&D Waiver

HCBS/BI Waiver

HCBS/Elderly Waiver

HCBS/CMH Waiver

HCBS/Habilitation

UW Funding

DHS Funding

Other

*All HCBS Waiver Referrals must be accompanied by a copy of the Current Service Plan, Social History and the Functional Assessment/SIS to be processed.

If other, please provide funding source:

Type of Service Community Based (check all that apply)

Summer Day

Daycare Enrichment

Ability Center

Service Center

Day Habilitation

Project SEARCH

Supported Employment

If you are unsure of these services, you can obtain a description online at www.arceci.org or you may leave this question blank.

Does the individual need 1:1 care in a group setting?

Yes

Guardian Information

Legal Guardian Name *

Home Phone

Cell Phone

Employer

Work Hours

Work Phone

Primary Caregiver Name (if different than guardian)

Relationship

Contact Phone

Referrals are processed within 5 business days of receipt. To access services, an intake must be conducted with the individual. Please list the day(s) and time(s) that work best for the individual, his/her guardian/caregiver, and any other parties who will be present at the intake.

Intake Day Preference

Intake Time Preference

I hereby acknowledge that all information in this document is accurate to the best of my knowledge. I understand that I am required to notify The Arc in writing of any changes to this document.

Signature

Reset Signature

Submitter Name

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