Family Home Medical Support Services

Residential Placement Referral & Intake Form

📞 570.339.4049 ✉ OurFamilyHomesInfo@gmail.com 🌐 familyhomemedical.net

* Required fields for initial screening

Referrer Information

Referrer Name *

Organization / Facility *

Title / Role

Callback Number *

Relationship to Individual

Individual Being Referred

Full Name *

Date of Birth *

County of Residence *

Current Location *

Situation *

Being discharged Proactive planning Crisis / urgent placement

Care Fit Assessment

Our two key fit factors

Mobility *

Independent Needs assistance Uses walker/cane Wheelchair Non-ambulatory

Continence *

Fully continent Occasional accidents Incontinent — managed independently Requires staff assistance

Behavioral Considerations — anything we should know?

Funding & Timeline

Funding Source *

Medicaid Waiver (CHC) Private Pay Pending / Unknown

CHC MCO (if applicable)

AmeriHealth Caritas UPMC Keystone First Not yet assigned

Desired Timeframe *

Immediate / Urgent Within 30 days 30–60 days 60+ days / Planning ahead

Notes & Next Steps

Additional Notes

Requested Next Step

Schedule tour Follow-up call Awaiting MCO authorization Send info packet

Our team will follow up within 1 business day.

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✓ Referral Received

Thank you — we've received this referral for .
A member of our placement team will be in touch within one business day.

Questions? Call us at 570.339.4049

Family Home Medical Support Services · Serving Northumberland County & Central Pennsylvania
familyhomemedical.net · Confidential referral document