Step1.Click on the Link to Download the Referral. Please Leave Staff Name and Date blank.
Step 2. Please Complete Section 1
For the person needing the service (Client):
- Name, DOB (Date of Birth), SSN (Social Security Number), and Sex
- Address and contact Phone number.
- Mailing address if it is different and Client’s Primary Language.
Companion Case (anyone in the home already receiving or also applying for services)
Referral Source is the individual assisting with this referral, Relationship = relationship to applicant and referral’s phone number.
Step 3. Fill in Section 2: Client’s Current Services/ Benefits check the boxes that apply.
If the Client has applied for or receives SSA, Pension, please check those applicable boxes. In addition, $ amount of income should be included.
Step 4. Fill in Section 3: Needs Assessment, please check all that apply for the client.
Step 5. Complete information about: Household, Caregiver name and phone number, Physician Name and Phone number.
Step 6. Complete the health summary diagnosis, you may use multiple lines. Include medical diagnosis of the client, include any recent hospitalizations.
Step 7. Check the box next to the service you are requesting for the client: for example, IHSS-In Home Supportive Services, APS-Adult Protective Services, etc. Use the “Other” box for other services not listed, for example: MOW-Meals on Wheels.
Step 8. You may PRINT OUT the FORM and FAX it in by clicking the Print Form Box.
Please Fax Completed Forms to 209 932-2663 or
Mail to: San Joaquin County Human Services Agency, Department of
Aging, PO Box 201056 Stockton, CA 95201
If you have any questions call Information and Assistance
At 209 468-1104