GSSSI Internal Referrals

THIS INFORMATION IS SENT ENCRYPTED AND IS SECURE.
After we receive your information it will be processed and forwarded to the appropriate department.
For your intake to be submitted, items with an * asterisk must be completed.

Program Being Requested

Home Delivered Meals (Must be age 60 or over, not a PCA client)	State Home Care (Must be age 60 or under 60 with a documented diagnosis of Alzheimer's or a related dementia)
AFC - Adult Foster Care (age 16 or older; must have at least 1 ADL need. Medication management is NOT an ADL qualifier. Consumer must NOT be able to live safely alone in the community)	Family Caregiver Support (case consult w/ x432 or x306) Caregiver must be age 18+ caring for person age 60+ w/without ADRD, Grandparent age 55+ caring for child 0-18 or disabled 18-59.

For the following services, the person you are referring MUST have MassHealth Standard or CommonHealth. We cannot take a referral for PCA, ADH or Nursing Home Screens without a valid MassHealth ID number. 🛈

Personal Care Attendant Program (any age, must need HANDS-ON assistance with at least 2 ADLs; Medications are considered an ADL when assistance is needed with administering medications.)

Long-Term Care Nursing Home Screen (any age, must have MassHealth Standard or CommonHealth)

Adult Day Health Screen (any age, must have MassHealth Standard or CommonHealth)

Reason for Referral -- Why Services Are Needed:
What activities of daily living (I/ADLs) does the consumer need help with? Please be as specific as possible. *

Referral Source

Is this a referral that has been screened out by a GSSSI department? *

Yes

No

If this is a referral screened out from a GSSSI department, what department was the referral screened out of? *

SAMS ID (If Applicable) *

Referral Source must be filled out or form cannot be submitted

Referral Source First Name *

Referral Source Last Name *

Department *

Extension *

Email Address

Consumer Being Referred

Consumer First Name *

Consumer Last Name *

Consumer Street Address *

Consumer Address Line 2

City *

State *

Zip Code *

Phone Number *

Secondary Phone Number

Email address

Consumer's Date of Birth * +

Consumer's Gender *

Male

Female

Does the consumer have MassHealth? *

Yes

No

Do not know

If yes, list the consumer's MassHealth ID:

Consumer's primary language (Ex., English, Spanish, French, etc.): *

Consumer's Marital Status:

Married

Single

Divorced

Widow/Widower

Consumer currently lives with: ( Alone, with spouse/partner, children, etc.?) *

Primary Emergency Contact/Caregiver

Must be filled out completely if making a PCA, AFC, or Family Caregiver Support Program Referral

First Name

Last Name

Date of Birth +

Relation to consumer:

Street Address

City

State

Email address

Zip Code

Phone Number

Secondary Phone Number

Consumer's Medical Information

Primary Care Physician (Please enter NONE if consumer does not have a PCP) *

Physician's Phone

Physician Address 1

Physician Address 2

State

Zip Code

Recent Hospitalization (list general dates and reasons):

Current Medical Conditions (list all that apply): *

Is the consumer currently receiving other community services and/or enrolled in another GSSSI program? *

If the consumer aware of this referral? *

Yes

No

COVID Questions: Please note that a positive Covid-19 diagnosis does NOT prevent a consumer from being opened up for services.

Has the consumer or anyone in the home been diagnosed with Covid-19 or is currently awaiting results from a Covid test? *

Yes

No No

Has the consumer or anyone in the home had a fever, cough, shortness of breath, experienced lost senses of taste or smell, or had a sore throat in the last 14 days? *

Yes

No No

Has the consumer or anyone in the home travelled outside the Commonwealth of Massachusetts in the last 14 days? *

Yes

No No

Does the consumer have any technology such as an Ipad, Chromebook, smart phone, etc., that could be used to conduct a virtual visit as needed? *

Yes

No No

If the consumer does not have any or cannot personally use technology that could be used to conduct a virtual visit, do they have any family, friends, or other informal supports that would be able to assist them? *

Yes

No No

Anything else that would be helpful for the assessing case manager to know? For example, large dogs in the home, only call in the afternoons, may refuse services, etc. *