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 - Caregiver must be age 18+ caring for person age 60+ w/without ADRD, Grandparent or other relative age 55+ caring for child 0-18 or disabled 18-59.
Options Counseling – an adult 60 years of age or older or an adult (18+) who has a disability.

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