GSSSI Internal Referrals

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

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.  🛈

Referral Source

Is this a referral that has been screened out by a GSSSI department? *
Referral Source must be filled out or form cannot be submitted

Consumer Being Referred

Consumer's Gender *
Does the consumer have MassHealth? *
Consumer's Marital Status:

Primary Emergency Contact/Caregiver

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

Consumer's Medical Information

If the consumer aware of this referral? *

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? *
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? *
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