SMC Adult Residential Care – selectedmedicalconsultants

Referring Party Information

(If you are self-referring, enter your own information.)

Name:

Organization / Agency (if applicable):

Role / Title:

Phone Number:

Email Address:

Best Way to Contact You: (Call / Text / Email)

Individual or Group Information

Is this request for:

Number of individuals needing placement (if group):

Primary Individual’s Name (or Group Representative):

Age / Age Range:

Gender (optional):

Population Type (check all that apply):

Veteran(s) Adults with physical disabilities Adults with chronic medical conditions Adults with mental health conditions Other (please describe)

Current Living Situation: (Home, hospital, shelter, skilled nursing, hotel, other)

Level of Care & Support Needs

Primary Diagnosis / Conditions (brief overview):

Any significant behavioral, safety, or supervision concerns? (If yes, briefly describe.)

Support Needs (check all that apply):

Assistance with ADLs (bathing dressing grooming etc.) Medication management / reminders Mobility support (wheelchair walker transfers etc.) Behavioral support / supervision Transportation to appointments Case management / coordination Meal preparation & nutrition Housekeeping / laundry support Other (please describe)

Funding & Program Information

Primary Funding Source (if known):

Are there any existing case managers, social workers, or VA contacts involved?

If yes, please list:

Name / Agency:

Phone / Email:

Timeframe & Location Preferences

Requested timeframe for placement:

Preferred City / Area: (e.g., Inland Empire, Riverside County, San Bernardino County, etc.)

Is transportation needed to the facility?

Additional Information

Is there anything else we should know to help us determine the best placement or services?