Refer a client

A simple intake form for case managers and care coordinators. Send us the basics and our team confirms eligibility and proposes a start date — usually within two business days.

1 Referring professional

Your name *

Title / role

Agency / lead agency *

County

Email *

Phone

2 Client information

Client name or initials *

Date of birth

County of financial responsibility

MA / PMI number (optional)

Waiver program *

Primary language / interpreter needs

3 Services requested

Homemaker / CleaningLight housekeeping and laundry. Homemaker / Home ManagementCleaning plus meal prep, shopping, errands, simple household tasks. Homemaker with Assistance (ADLs)Cleaning plus incidental help with daily living activities.

Estimated authorized hours / week

Requested start date

4 Notes & consent

Special considerations or notes

Referral authorizationI confirm I am authorized to share this referral information for the purpose of arranging services.

Please complete the required fields marked with an asterisk and confirm authorization.

Prefer to send directly? Email the same details to [intake@yourdomain.com].

✓

Referral ready to send

Here's a clean summary of the referral. Copy it, or open your email client to send it straight to our intake team.

Open in email