Ihss Referral Form is a great way to connect with Ihss and get the help you need. It's important to have all of your information ready when you fill out the form, so that you can be connected with the right person as soon as possible. This form is for residents of Los Angeles County, so please make sure you are in the correct county before submitting it. The sooner you submit the form, the sooner you'll be connected with someone from Ihss who can help.
If you would like first learn how much time you will need to fill out the ihss referral form and the number of pages it's got, here is some basic data that may be helpful.
Question | Answer |
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Form Name | Ihss Referral Form |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | ihss application form pdf, apply ihss online, ihss application form, application for ihss |
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Date Sent: |
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Ple ase answe r all q ue stio ns and print c le arly |
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Fax to SF HSA Department of Aging and Adult Services Program: (415) |
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Questions? Call: (415) |
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IHSS Applicant |
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Spouse (If in the home) |
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Last Name |
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First Name |
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MI |
Last Name |
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First Name |
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MI |
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Sex (M/F) |
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Sex (M/F) |
/Transgender (Y/N) |
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Birth date |
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Sexual Orientation |
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Soc. Sec. Number |
Birth date |
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Sexual Orientation |
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Soc. Sec. Number |
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Street Address |
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Zip |
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Is Spouse an IHSS Recipient? |
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Y |
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N |
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Phone |
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Ethnicity: |
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Languages: |
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Is Spouse able to do housework? Y |
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N |
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If no, why not? |
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Does applicant receive Supplemental Security Income |
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Spouse’s MD Information: |
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(SSI)? Y |
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N |
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Name: |
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Address: |
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Is the applicant enrolled in |
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N |
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City: |
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CA Zip: |
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Phone: ( |
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Fax: ( |
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Emergency Contact Name: |
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Relation: |
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Phone: ( |
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Last name |
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First name |
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Please circle one: |
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Relation: |
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Phone: ( |
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Last name |
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First name |
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Please circle one: |
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Others in Household: |
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Lives Alone |
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Number of Household Members: ( |
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Other IHSS Recipients in household? |
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Y |
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N |
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If yes, Soc. Sec. Number: |
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- |
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Name of IHSS Recipient: |
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Relation: |
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Last name |
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First name |
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Medical Information |
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Diagnosis/ Medical Condition: |
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MD Name: |
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La st Na me |
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First Na me |
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Address: |
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City: |
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CA Zip: |
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Phone: |
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Ext: |
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Fax: |
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Ext: |
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Comments: |
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Referent Name: For non self‐referrals, please attach applicant’s signature of Authorization for Release of Information.
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Phone: ( |
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ext. |
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Last name |
First name |
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Agency: |
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Re la tio n: |
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If hospitalized, Hospital: |
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Campus/ Site: |
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Floor: |
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Most Recent or Anticipated discharge date / |
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Emergency |
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Is emergency |
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***we a re una ble to a utho rize ER se rvic e s witho ut |
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the health care certification form SOC 873 *** |
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*If yes, why are emergency services needed? |
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Fo rm 3012 (re v. 06/ 12) |
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Pa g e 1 o f 2 |
The information on this page will help us assess your needs and respond to your request for services. If the form is
not completed in full, your application will not be accepted.
*We a re unab le to autho rize e me rg e nc y o
Functional Ability
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Unknown |
Independent |
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Verbal |
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Some human |
Lots of human |
Dependent |
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Assist |
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help |
help |
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Transfer mobility |
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Bathing |
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Dressing |
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Toileting |
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Eating |
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Grooming |
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Ambulating (walking) |
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Mobility indoors |
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Stair climbing |
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Managing medicines |
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Shopping |
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Meal prep & clean up |
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Telephone |
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Transportation |
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Managing money |
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Light housework |
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Heavy housework |
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Laundry |
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Risks |
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Does the client currently exhibit |
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Active |
Past |
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Unknown |
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Explain |
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or have history of… |
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History |
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Violent Behavior |
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Financial management/ Eviction |
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Support System |
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How are your service needs currently being met? Please be as specific as possible and include information about current caregiver(s) and areas of need.
How will you be able to meet your service needs until IHSS eligibility and services are established?
Services
Please list any services you currently receive:
Are you interested in learning more about the following services?
On Lok Lifeways/ PACE program (a comprehensive
Adult Day Health Care thro ug h
Other services:
***Please note that in order to receive IHSS you must be on
Fo rm 3012 (re v. 06/ 12) |
Pa g e 2 o f 2 |