Aging Services, Inc./ Milestones Adult Center
                          Intake Application/ASI Referral
Please fax to (319) 398-3954 or
mail to MILESTONES Adult Day Health Center 1725 0 Avenue, NW  Cedar Rapids, IA 52405

NAME_____________________________________ DATE________   STAFF_____________

ADDRESS_______________________ CITY___________________ PHONE_______________

REFERRED BY_________________________________ PHONE________________


IS CLIENT AWARE OF REFERRAL?        _______(YES)   ________(NO)

CAN WE REVEAL REFERRAL SOURCE TO CLIENT?   _______(YES) ________(NO)

CASE MANAGEMENT REFERRAL?    ________(YES) _______(NO)

CLIENT BIRTH DATE______________   MARITAL STATUS_________ PHYSICIANS____________

OTHERS IN HOUSEHOLD/RELATIONSHIP_______________________________________________

CONTACT PERSON_________________________________ PHONE___________________

SOURCE/AMOUNT OF INCOME:  SS_______________         ACTIVE AGENCIES________________

PENSION_______________                                             _______________
 
SSI________________                                                _______________

OTHER________________                                              _______________


IS THERE AN EMERGENCY NEED?_________________________________________________________

____________________________________________________________________________________

PRESENTING PROBLEM/REASON FOR REFERRAL:
_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

PREVIOUS CONTACT WITH AGING SERVICES, INC.             ________(YES)     ________(NO)

-webformref