Page 1 of 1

Bright Horizons Living Client Referral & Placement Intake Form

(For Agencies/Case Managers/Social Workers)

REFERRING AGENCY INFORMATION

Agency Name:

*

Referring Staff Name & Title

*

Phone Number:

*

Email Address

*

Preferred Method of Communication:

*

Preferred Method of Communication:

A

Email

B

Phone

Date of Referral:

*

CLIENT IN FORMATION

Client Full Name

*

Date of Birth

*

Gender:

*

Phone (if applicable):

*

Veteran Status:

*

Veteran Status:

No

Yes

Re entry Status (Justice-Involved)

*

Re entry Status (Justice-Involved)

No

Yes

Registered Sex Offender

*

Registered Sex Offender

A

Yes

B

No

PLACEMENT NEEDS

Requested Move-In Date:

*

Type of Room Requested:

*

Length of Stay Anticipated:

*

Reason for Placement:

*

If Others Please Explain

*

Brief Summary of Current Situation:

FUNCTIONAL STATUS

Is the client independent with:

Activities of DailyLiving (ADLs)?

*

Activities of DailyLiving (ADLs)?

A

No

B

Yes

Medication Management?

*

Medication Management?

A

No

B

Yes

Mobility?☐

*

Mobility?☐

Any cognitive concerns?

*

Any cognitive concerns?

No

Yes

MEDICAL & MENTAL HEALTH

Primary Diagnoses (if applicable):

*

Serious Mental Health Diagnosis?

*

Serious Mental Health Diagnosis?

A

No

B

Yes

Substance Use History?

*

Substance Use History?

A

No

B

Yes

Currently in treatment?

*

Currently in treatment?

A

No

B

Yes

Current Medications?

*

Current Medications?

A

No

B

Yes

Any behaviors that may impact communal living

*

INCOME & FUNDING

Monthly Income Source:

*

Monthly Income Source:

Employment

SSI/SSDI

VA Benefits

None

Other

Monthly Income Amount (if known):$

*

Is rent assistance available?

*

ADDITIONAL INFORMATION

Emergency Contact Name & Phone:

*

Has the client been informed of house expectations and communal living?

*

Has the client been informed of house expectations and communal living?

A

No

B

Yes

Additional Notes:

*