Referral Anyone can complete this form to add a referral for services at RFI. NOTE: RFI does not have Licensed homes for minors at this time.Referral InformationMember Name/Initials: Name: Member Age: Age: Location County: Diagnoses:List mental health diagnoses and medical conditions. Add RemoveService(s) Requested: Day Program Community Networking Community Living and Support Respite Supported Employment Residential - AFL Supported Living Service Needs/Hours:How many hours/days of each service are being requested? (Example: CLS - 28 hours; Day Supports - 35 hours) Funding Source: 1915i DSS LTCS NC Innovations Unsure No funding Other Person Making Referral: Parent/Caregiver Appointed Guardian DSS Care Manager/Extender Other Other Does the member have behaviors? Yes No If yes, please describe:(i.e. Property Destruction, Self-injurious, Aggressive, Inappropriate touch, etc.) Add RemoveDoes the member require personal care? Yes No If yes, please describe:(i.e. Needs full support in restroom, verbal reminders, etc.) Add RemoveName of Person Making Referral: Name and Relationship to Member: Contact Information:Phone: Contact Information: Email: Is there a Care Manager involved?YesNoUnsureCare Manager Name (if not listed above): Name: Agency: Anything other information:Upload Documents:Upload any documents that could be helpful in evaluating the referral: Accepted file types: pdf, doc, docx, Max. file size: 25 MB.
