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Referrals
Refer To Home Care
Refer To GUIDE Program
Personal Care Services
Contact Us
Home
About
Home Health
Virtual Care
Referrals
Refer To Home Care
Refer To GUIDE Program
Personal Care Services
Contact Us
Personal Care Services
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Personal Care Services are paid for by private pay, Medicaid, and the Medicaid Waiver Program. If you cannot afford to pay yourself for Personal Care, Avocare will assist you in applying for Medicaid or the Medicaid Waiver Program in your area.
You can choose a caregiver that is a family member, friend, or significant other to provide your care. If you do not have a person to provide care, we can provide the care through our agency or other partner agencies.
Referral Information
Date of Referral
Name of Person Referring
*
Referring Person Phone
*
Demographic Information
Patient Last Name
*
Patient First Name
*
Date of Birth
*
Sex
Primary Language
Select
English
Spanish
Arabic
Hindi
Polish
Italian
French
Armenian
Chinese
Bengali
Other
Marital Status
Select
Single
Married
Widowed
Divorced
Separated
Primary Phone Number
*
Phone Type
Select
Mobile
Landline/VOIP
Email Address
Address for Care
City
State
Michigan
Michigan
Ohio
Illinois
Zip Code
Residence Type
Select
My Own Home
Family Member Home
Senior Apartments
Assisted Living
Group Home (Unlicensed)
Boarding Home
I Currently Live With:
Select
I Live Alone
Spouse
Family Members
Friends/Significant Others
Other Group Home Residents
Select who you share your home with currently
OK to Text
Select
Yes
No
Contact Person
that Perform Caregiver
Contact Person Name
Contact Phone
Contact Email
Contact Relationship to Patient
Select
Spouse
Family Member
Friend/Significant Other
Guardian/DPOA
OK to Text
Select
Yes
No
Caregiver Information (If Applies)
Caregiver Name
Caregiver Phone
Caregiver Email
Caregiver Relationship
Select
Family
Spouse
Friend
Significant Other
Agency Caregiver
Health Information
List Conditions that Make it Difficult to Perform Daily Tasks
Diagnosis(es)
List all known diagnosis(es)
Cognitive
Difficulty Remembering Things Daily
Difficulty Making Decisions
Diagnosis of Dementia
Diagnosis of Alzheimer's Disease
Periods of Confusion
Check all that applies
Psychiatric
Depression
Anxiety
Inappropriate Behaviors
Hallucinations or Delusions
Diagnosis of Schizophrenia or Bipolar DO
Check all that apply
Mobility
Needs Help Walking
Needs Help Transferring
Has Pain with Moving
Problems with Balance & Coordination
Cannot Leave Home Alone
Check all that applies throughout the month
Needs Help With:
Housekeeping Cleaning
Cooking
Laundry
Shopping
Paying Bills
Check all areas you need assistance with throughout the month
Needs Help With:
Bathing
Dressing
Toileting
Eating
Getting Up and Walking
Check all areas you need assistance with throughout the month
Assistive Devices
Cane
Walker
Wheelchair
Grab Bars
Wheelchair Ramp or Lift
Identify All assistive devices you use at home
Are You Responsible for Yourself?
*
I am responsible for myself
I have a Guardian
I have a Durable Power of Attorney
A family member helps me with financial and legal affairs
I need help with financial, medical, & legal affairs
Identify if you are responsible for yourself and can make your own decisions, or if you have a person or agency empowered to make decisions for you.
I Do Not Have Enough Money During the Month For:
Housing
Food
Medications
Transportation
Caregiver
Check each area for which you do not have enough money to afford each month
Approximate Monthly Income
No Income
0-500 Dollars
500-1000 Dollars
1000-1500 Dollars
1500-2000 Dollars
2000-2500 Dollars
2500-3000 Dollars
Above 3000 Dollars
Select Income Level
Primary Health Insurance
*
Medicare A & B
Medicare A & B with Medicaid
Medicare Advantage Plan
Retirement Health Plan
Medicaid Only
Additional Clinical Information, Needs, or Complicating Factors
Consent and Acknowledgment of Participation
Consent to Proceed
*
I hereby attest that the patient above agrees to participate in the qualification for personal care services and consents to Avocare using their health information for qualification and placement of personal care services.
Signature
Clear Signature
Submit
