Referral form

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HomeReferral form

Please fill out the following referral form for our team to review. If you would like a paper copy of this referral form to fax, please email us at zencarehealth@gmail.com

Referral Form

First Name

Last Name

Phone Number

Email

Choose an option

Brief Questionnaire

Waiver Programs or Private Pay?

Private Pay CADI Waiver TBI Waiver Elderly Waiver Individual is on a different type of waiver program. Individual is NOT on a waiver program.

Is the recipient of services 55 years of age and older?

No Yes

Is the recipient of services in need of an accessible home (no stairs, shower accessibility, etc.)?

No Yes Yes, to a certain degree.

Is the recipient of services in need of 24-hour customized assisted living services?

No Yes

Does the recipient of services require transfers?

No Yes, 1-person transfer. Yes, 2-person transfer.

Seeking what type of services?

Projected Intake?

If waivered, Case Mix (A, B, C, etc)?

Detemine the level of care needed.

Level 1 Care (basic services, med reminders, etc.). Level 2 Care (intermediate care). Level 3 Care (moderate-high level, multiple ADL's). Level 4 Care (high level of need, mental health needs, multiple ADL's).

Additional Information

Medical/Personal Needs

Behavioral/Mental Health Summary

Physical Health Summary

Is the recipient of services currently living in an assisted living facility?

No Yes

Is the recipient of services currently participating in a day program?

No Yes

Is the individual currently on a Restricted Recipient Program?

No Yes

Determine the staffing support needed.

1:1 1:2 1:3 1:4

Does the recipient of services require visual safety checks during sleep hours?

No Yes

Unique Circumstances/Needs?

Emergency Contact Information

First Name

Last Name

Email

Phone Number

Waiver Case Manager

First Name

Last Name

Email

Phone Number

Legal Guardian/Representative

First Name

Last Name

Email

Phone Number

Supporting Documents

Please upload a Coordinated Supports & Services Plan (CSSP) if available.

Please upload a MnChoice Assessment/Summary if available

Additional Supporting Documents.

I declare that the information I’ve provided is accurate & complete.

At Zencare Health, our commitment is to deliver the highest quality of care and services, nurturing the health and well-being of every individual we serve.

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Get In Touch

zencarehealth@gmail.com
612-638-7379
1011 Burns Ave, Saint Paul, MN, 55106