Client Referral Form

Please read this information before filling out the form. Once you have read and typed in your name to acknowledge your understanding and agreement, proceed with completing the form by clicking the NEXT button.

INELIGIBLE CLIENTS

Clients will not be served if their homes are unsafe for the Senior Companion.

Examples of unsafe conditions include, but are not limited to:

• Client with contagious diseases.
• Bed bugs.
• Unsanitary conditions such as clutter or accumulated garbage.
• Presence of non-domesticated animals, insects, or rodents.
• Inadequate heat or air ventilation.
• Presence of noxious fumes.
• Presence of drugs, paraphernalia, or weapons.
• Lack of safe parking facilities.
• Improperly sealed or stored hazardous materials such as gasoline, solvents, or paints.
• Absence of working smoke detectors.
• Lack of suitable emergency escape due to a cluttered living area.
• Lack of adequately maintained elevators and stairwells or other barriers to exit.
• Ice or snow on the client's sidewalk or driveway, which makes getting to the client's doorway difficult.

A client whose home or person creates unsafe conditions that could harm the health of the Senior Companion will not receive service until the issue is resolved and remedied.

Clients may need to provide certification confirming there is no longer a health threat to visitors.

I acknowledge that I have read the "Ineligible Client" information above. I understand the information, and do not believe the condition of my home makes me ineligible for the Senior Companion Program.