Community & Family Support Services – 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

Others (please describe )

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

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?

I understand that submitting this form is an inquiry only and does not guarantee placement. SMC Adult Residential Care will review the information provided and contact me to discuss availability, eligibility, and next steps.

Community & Family Support Services Request Form

Referring Party Information

Individual or Group Information

Level of Care & Support Needs

Funding & Program Information

Timeframe & Location Preferences

Additional Information