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1488 Jewel Dr Woodbury, MN 55125

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Referral Form

Golden Arms Health Care LLC > Referral Form

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First Name *

Last Name *

Street Address

Address Line 2

City

State/Province

ZIP / Postal Code

Client Phone Number *

Referral Source

Referring Case Manager/Care Coordinator Name

First Name

Last Name

Referring Case Manager/Care Coordinator Email

Referring Case Manager/Care Coordinator Phone Number

Guardian/Responsible Party's First and Last Name

First Name

Last Name

Guardian/Responsible Party's Callback Phone Number

Desired Service

Comments

Resident Information
Basic Information for person seeking services
1. Resident's First Name*
2. Resident's Last Name*
3. Resident's Birth Date*
4. Resident's Age*
Please enter a number from 0 to 105.
5. Resident's Gender*
6. Dementia or Related Diagnosis?*
7. Guardianship Status:*
Primary reason for seeking residential services at Golden Arms Health Care LLC?*
Current Housing Info
8. Resident's Current Living Situation*
Other (please indicate)
Does the resident/client pay rent at current housing placement?*
How much is the rent at current housing?*
Payment Method
We accept CADI, BI and Elderly Waiver at move-in. Residents do not need to pay privately before moving in.
9. Level of support requested*
10. Approved allocation level*
11. Who will pay rent at Golden Arms Health Care LLC?*
12. Who will pay for the care services at Golden Arms Health Care LLC?*
13. Personal Income Source*
14. Personal Income Amount*
Has the resident/client been approved for Group Residential Housing (GRH) ?*
Group Residential Housing (GRH) is a state-funded income supplement program that pays for room-and-board costs for low-income adults who have been placed in a licensed or registered setting with which a county human service agency has negotiated a monthly rate
Case Management Team
15. Case Manager's First Name*
16. Case Manager's Last Name*
17. Case Manager's Phone #*
18. Case Manager's Email*
19. Rep Payee's First Name
20. Rep Payee's Last Name
21. Rep Payee's Phone #
22. Rep Payee's Email
Hidden
Medical Information
Hidden
What things are currently working well for the individual? (Routines, interests, hobbies)
Hidden
What are some of the current challenges?
Hidden
Level of Care Needed (Staffing Pattern)
Hidden
Special Needs (Dietary, Medical, Accessibility, etc.):
Housing Preferences
23. Floor Preference
24. Housemate Gender Preference
25. Mobility Status (client gets around in the house/community)*
26. Room Preference*
27. Within what time frame would you like to make the move?
28. Enter additional notes (if any)
Assistance Animals/Pets
29. Will an animal accompany the resident/client to Golden Arms Health Care LLC?*
30. Is the animal a service animal?*
31. Is the animal an emotional support animal?*
32. Is the animal a pet?*
Assessment and Supporting Documents Available
33. Does the resident/client have any court-ordered treatment requirements or restrictions?
34. Does the resident/client have a Jarvis order?
35. Does the resident/client have a Guardianship order?
36. Does the resident/client have a Commitment order?
37. Select below the assessment and supporting documents available:*
- ① MnCHOICES Assessment or Eligibility Summary
- ② PCA Summary
- ③ Coordinated Service and Support Plan (CSSP)
- ④ Community Support Plan (CSP)
- ⑤ Psychiatric or Diagnostic Assessments
- ⑥ Hospitalization notes/Medical/ Mental health history notes
- ⑦ Behavioral assessments and support plans
- ⑧ Psychological/neuropsychological assessments
- ⑨ Civil commitment orders
- ⑩ Provisional discharge agreements
- ⑪ Functional Assessments
- ⑫ Positive Behavior Support Plan
- ⑬ Discharge Paperwork from Current Placement
- ⑭ Intensive Support Self-Management Assessment (ISP)
- ⑮ Person Centered Plan (PCP)
- ⑯ Individual Placement and Support (IPS)
- ⑰ Individual Abuse Prevention Plan (IAPP)
38. Comments or Special Reports
39. Interagency Medication Reconciliation
Our team will work with the resident’s care team (including case manager) to streamline the interagency medication reconciliation process. This process comprises five steps: (1) review list of current medications; (2) compile a list of medications to be prescribed (if any); (3) compare the medications on the two lists; (4) make clinical decisions based on the comparison; and (5) communicate the new list to resident/client and the staff.
40. Do you know whether the resident/client will have at least 3 days supply of current medications?*
If no, please enter more info
Phone
This field is for validation purposes and should be left unchanged.

Resident Information
Basic Information for person seeking services
1. Resident's First Name*
2. Resident's Last Name*
3. Resident's Birth Date*
4. Resident's Age*
Please enter a number from 0 to 105.
5. Resident's Gender*
6. Dementia or Related Diagnosis?*
7. Guardianship Status:*
Primary reason for seeking residential services at Golden Arms Health Care LLC?*
Current Housing Info
8. Resident's Current Living Situation*
Other (please indicate)
Does the resident/client pay rent at current housing placement?*
How much is the rent at current housing?*
Payment Method
We accept CADI, BI and Elderly Waiver at move-in. Residents do not need to pay privately before moving in.
9. Level of support requested*
10. Approved allocation level*
11. Who will pay rent at Golden Arms Health Care LLC?*
12. Who will pay for the care services at Golden Arms Health Care LLC?*
13. Personal Income Source*
14. Personal Income Amount*
Has the resident/client been approved for Group Residential Housing (GRH) ?*
Group Residential Housing (GRH) is a state-funded income supplement program that pays for room-and-board costs for low-income adults who have been placed in a licensed or registered setting with which a county human service agency has negotiated a monthly rate
Case Management Team
15. Case Manager's First Name*
16. Case Manager's Last Name*
17. Case Manager's Phone #*
18. Case Manager's Email*
19. Rep Payee's First Name
20. Rep Payee's Last Name
21. Rep Payee's Phone #
22. Rep Payee's Email
Hidden
Medical Information
Hidden
What things are currently working well for the individual? (Routines, interests, hobbies)
Hidden
What are some of the current challenges?
Hidden
Level of Care Needed (Staffing Pattern)
Hidden
Special Needs (Dietary, Medical, Accessibility, etc.):
Housing Preferences
23. Floor Preference
24. Housemate Gender Preference
25. Mobility Status (client gets around in the house/community)*
26. Room Preference*
27. Within what time frame would you like to make the move?
28. Enter additional notes (if any)
Assistance Animals/Pets
29. Will an animal accompany the resident/client to Golden Arms Health Care LLC?*
30. Is the animal a service animal?*
31. Is the animal an emotional support animal?*
32. Is the animal a pet?*
Assessment and Supporting Documents Available
33. Does the resident/client have any court-ordered treatment requirements or restrictions?
34. Does the resident/client have a Jarvis order?
35. Does the resident/client have a Guardianship order?
36. Does the resident/client have a Commitment order?
37. Select below the assessment and supporting documents available:*
- ① MnCHOICES Assessment or Eligibility Summary
- ② PCA Summary
- ③ Coordinated Service and Support Plan (CSSP)
- ④ Community Support Plan (CSP)
- ⑤ Psychiatric or Diagnostic Assessments
- ⑥ Hospitalization notes/Medical/ Mental health history notes
- ⑦ Behavioral assessments and support plans
- ⑧ Psychological/neuropsychological assessments
- ⑨ Civil commitment orders
- ⑩ Provisional discharge agreements
- ⑪ Functional Assessments
- ⑫ Positive Behavior Support Plan
- ⑬ Discharge Paperwork from Current Placement
- ⑭ Intensive Support Self-Management Assessment (ISP)
- ⑮ Person Centered Plan (PCP)
- ⑯ Individual Placement and Support (IPS)
- ⑰ Individual Abuse Prevention Plan (IAPP)
38. Comments or Special Reports
39. Interagency Medication Reconciliation
Our team will work with the resident’s care team (including case manager) to streamline the interagency medication reconciliation process. This process comprises five steps: (1) review list of current medications; (2) compile a list of medications to be prescribed (if any); (3) compare the medications on the two lists; (4) make clinical decisions based on the comparison; and (5) communicate the new list to resident/client and the staff.
40. Do you know whether the resident/client will have at least 3 days supply of current medications?*
If no, please enter more info
Name
This field is for validation purposes and should be left unchanged.

Referral Form

Golden Arms Home Healthcare was founded in 2019 by seasoned home healthcare professionals with over two decades of cumulative experience in the healthcare industry.

1488 Jewel Dr
Woodbury, MN 55125

Talk To Our Support 612-723-8364

intake@goldenarmscare.com

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About Us
Our Services
3D Tour
Virtual Tour
Our Forms
- Referral Form
- Application Form
Home Care Services
Contact Us

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