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Home Safety Modification Form
Referred By
First Name
Last Name
Organization
Email
Phone
Date Submitted
Client Information
First Name
Last Name
Street Address
City
State
- None -
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American Samoa
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Tennessee
Texas
Utah
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Washington
West Virginia
Wisconsin
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ZIP Code
Preferred Phone
Preferred Email
Best time to reach client?
Gender
Male
Female
Marital Status
Married
Single
Date of Birth
Family member to contact?
Phone number
Care Giver's Information
Name
Care Giver Phone
Relationship
Screening Questions
Does the client live alone?
Yes
No
Are there any pets in the home?
Yes
No
Is the client a veteran?
Yes
No
Does the client own or rent the home?
Rent
Own
Monthly Income
$
Does the client receive CalFresh support?
Yes
No
Insurance Type
Medicare
Medi-Cal
Other Insurance
Referred to Care Management?
Yes
No
Is the client English speaking?
Yes
No
If no, is there an interpreter available?
Yes
No
Language (if other than English)?
Race/Ethnicity
African American
Asian
Caucasian
Hispanic
Native American
Pacific Islander
Alaska Native
Other Race/Ethnicity
Reason for Referral
Are there any medical conditions we should know about?
History of Falls
Has the client had a fall?
Yes
No
If yes, when and where?
How many falls in the past 6 months?
Was 911 called after the fall?
Yes
No
Did the call result in ambulance ride/hospital admission?
Yes
No
Exercise
Is the client exercising?
Yes
No
Duration and frequency of exercise?
Interest in in-home exercise program?
Yes
No
Client Care
Other fall prevention programs available to client
Yes
No
What other agencies are involved in client's care? (ex: Home Health, IHSS, unknown)
Submit