Washington State Community Living Connections

Providers: Use this HIPAA-compliant form to refer your patient to community service

Note: * Indicates required fields

Provider Name:*

Hospital/Clinic/Agency Name:*

Provider Phone number:*

Provider Email address:*

Patient Information

Please enter contact information for your patient and/or the patients alternate contact.

Last Name

First Name

Date of birth

Phone number

Email address

Address

County *

Alternate contact

Check if Primary Contact

Last Name

First Name

Phone number

Email address

County

Please indicate concerns you have regarding your patient's current situation.

Select all that apply or use comment box below to elaborate or indicate a concern not included on this list:

Falls: Balance issues, Falls or Fear of Falling

Chronic Disease(s): Challenges Managing Chronic Conditions

Nutrition: Meal Delivery, Congregate Meals, Nutrition Education

Caregiver Education and Support

Exercise, Wellness, Social Activities

Medical Equipment

Medication Reminders or other Assistive Technology & Devices

Memory Loss, Alzheimer’s and Dementia Support & Information

Help with Activities of Daily Living: Bathing, Grooming, Dressing

Other: (please identify other services and/or supports)

Comments

Is this a Care Transitions Referral?

I have obtained permission to release the above information to the local Area Agency on Aging, Information & Assistance Program, to follow up with services that may assist in meeting my patient's current needs. *

Note: Not all services may be available in all areas.

If you are a service provider interested in being included in Washington State's CLC Resource Directory, please fill in the following information and click on the Submit button. Someone from a local CLC will then contact you.

Note: * is a required field

Organization Name *

Address

City

State

ZIP Code

Select a County *

Contact Name *

Email *

Phone *

What is your organization type? *

Enter brief description of your services and programs:

Your Name *

Title *