Referral Source Owner
*
Elena
Migzy
Ted
Referral Source Full Name
*
Organization
Phone
Email
Rating
Referral Rating
A - Very High Opportunity to Refer (once or more per week)
B - High Opportunity to Refer (once or more every couple of weeks)
C - Ability to Refer (once or more per month
D- Not Sure
F- No Ability to Refer
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Facility Type
Type of Facility
Assisted Living
Skilled Nursing Facility
Independent Living
Geriatric Care Manager/ Life Care Manager
Care Home/ Group Home
Hospital
Home Health Care Agency
Hospice Agency
Non-Medical Home Care
DME (Durable Medical Equipment)
Fiduciary (Conservator/Guardian)
Elder Law Attorney
Senior Center
Adult Day Care
Other (if other, add to notes)
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Multiple Facilities?
Other Services or Facilities on Campus?
Memory Care
Skilled Nursing Facility
Independent Living
Assisted Living
Other (add to notes)
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Occupancy
How Many Beds/Residents?
5-14
15-25
26-40
41-55
56-70
71-100
101-115
More than 115
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Medicaid %
Percentage of Medicaid Beds/Residents
0
1%- 25%
26% - 50%
Over 50%
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Payment Accepted
Insurance or Payment Types (Choose Multiple)
Private Pay Only
Medicare
Medicaid
Commercial Insurances
Long-Term Care Insurance
Other (add info in notes)
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Date of Last Contact
Type of Last Contact
Type of Last Visit or Contact
Face-to-Face Meeting
Drop by
Appt
Email
Phone
Text
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1st Contact Made
Referral Contact Made (Choose Multiple)
Face-to-Face
Drop Off Only
Voicemail
Text
Email
Inservice
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Communication
Preferred Method of Communication (Choose Multiple)
Text
Email
Phone Call
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Follow Up After They Refer a Client
Prefers Follow Up After They Refer a Client to You?
YES
NO
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Extra Notes
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