Professional Referrals Intake Form - WestMass ElderCare Inc.

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To apply for WMEC services or make a referral for someone else, please complete all sections of the secure form below.

A WMEC staff member will contact you shortly. WMEC contacts consumers by phone, video, and/or in-person, always assessing for safety and using PPE.

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Professional Referrals – Online Intake Singe Page Form

Consumer’s Personal Information

First Name: *

Last name: *

Address 1: *

Address 2:

Apartment Number:

City: *

State: *

Zip: *

Phone Number *

Date of Birth *

Gender: *

Medicaid:

Yes

No

Primary Language Spoken:

Speaks English: *

Yes

No

If “No” is there someone who can interpret?

Yes

No

Marital Status:

Lives with:

Referral Source

First Name: *

Last name: *

Address 1:

Address 2:

Apartment Number:

City:

State:

Zip:

Phone Number *

Work Phone

E-mail:

Relation to or Profession (if applicable): *

Consumer’s Medical Information

Primary Care Physician:

Physician’s Phone:

Physician Address 1:

Physician Address 2:

State:

Physician Zip:

Date of last visit:

Recent Hospitalization (list general dates and reasons):

Current Medical Conditions (list all that apply):

Nursing Home?

Yes

No

Name of Nursing Home:

Nursing Home's Phone:

Emergency Contact 1

First Name:

Last name:

Address 1:

Address 2:

Apartment Number:

City:

State:

Zip:

Phone Number

Work Phone

E-mail:

Relation to or Profession (if applicable):

Emergency Contact 2

First Name:

Last name:

Address 1:

Address 2:

Apartment Number:

City:

State:

Zip:

Phone Number

Work Phone

E-mail:

Relation to or Profession (if applicable):

Access to Technology

Does the consumer have technology such as a tablet, lap top, smart phone, etc., that could be used to conduct a virtual visit if needed? *

Yes

No

If the consumer does not have or cannot personally use technology needed to conduct a virtual visit, does the consumer have any informal supports that may be able to assist? *

Yes

No

COVID-19 Screening

Has the consumer or anyone in the home been diagnosed with COVID-19 or currently awaiting results from a COVID-19 test? *

Yes

No

Has the consumer or anyone in the home had a fever, cough, shortness or breath, experience loss of senses of taste or smell, or had a sore throat in the last 14 days? *

Yes

No

Has the consumer or anyone in the home traveled outside of Massachusetts in the last 14 days? *

Yes

No

Additional Information

Services Requested *

Reason Consumer Needs Services *

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WestMass ElderCare is a private, non-profit agency founded 1974 which is funded in part by grants and contracts from the Massachusetts Executive Office of Elder Affairs. We are part of a network of Aging Services Access Points and Area Agencies on Aging.

WestMass ElderCare is a member of the Pioneer Valley Aging and Disabilities Resource Consortium.
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