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Oregon Provider Client Referral Form Serving Multnomah and Clackamas County 39330 Proctor Blvd. Sandy Oregon 97055 PO Box 175 Sandy, OR 97055 Office: 503.427.8448
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Email
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Today's Date:
MM
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DD
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YYYY
Name and relationship of individual filling out this form
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Individual requesting services first name or initials
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Individuals Age
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City, county, and roughly where the individual lives (Example: SE PDX)
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When does the individual need services
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What days days and times does the individual need weekly
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Does the induvial needs medical supports and if so please give a brief description.
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Individuals preferences for DSP/EP such as age, gender, or other requirements
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Does the individual have mobility challenges or require any adaptive equipment:
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Does the individual have any serious known risks or Protocals?
Seizure
Falls
Aspiration/Choking
Diabetic
Dehydration
Constipation
Physical aggression
Verbal aggression
Other:
Does the individual have require assistance with hygiene, toileting, and/or other ADLS. If so please give a brief description
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Does the individual have mental health diagnoses or any history of challenging mental health concerns?
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Does the individual have a Positive Behavioral Support Plan? Have they completed a Functional Behavior Assessment?
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What types of supports are the individual wanting
OR004 - Comm Transp, Mileage WE - Community
OR526 - Attendant Care, home or community
OR542 - Day Support Activity, non-work W2 - Community
OR542 - Day Support Activity, non-work RS - 1:1 Solo - Community
OR005 - Agency Transp, Mileage WD - To/From Work
Discovery OR539 - Career Explore/Disc WA - Emp Profile Outcome
OR401 - Individual Support Employment W6
OR541 - Employment Path W2 - Community
Short/Long Term Job Coaching
Career Exploration with OCB or VR
Job Development with OCB or VR
Job Coaching with OCB or VR
Is there any other pertinent information about the individuals support needs?
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What type of activities is the individual currently involved with?
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What are the individual short- and long-term goals?
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Is the individual currently working? If so what supports and services do they have or need?
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If the individual is not working do they have employment or Discovery goals?
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Is the individual have reliable and dependable in terms of scheduling services and keeping commitments?
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FOR ADMINISTRATION USE ONLY
Patricia Kendrick | Agency Director |
pkendrick@oregonprovider.com
Rebecca Smith | Employment Director |
rsmith@oregonprovider.com
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