form-tester Eligibility Requirements 18 years old and up (not in another Case Management Program) Uninsured, private insurance, CICP, or Medicare Cannot be on Medicaid, (Medicaid members can be referred to TCHNetwork’s Medicaid Care Coordinator) A patient with the Basin Clinic (there is a plan to expand in the spring to all West End residents) When in doubt, ask. Contact Amy Rowan at firstname.lastname@example.org or 970.614.7311 M-F 8-5 for assistance. Verification of Client Consent Client is aware and agrees to being referred to for Wrap Around Care Coordination?* YesNo Please inform the client and obtain consent prior to proceeding. Referring Party/Agency First Name* Last Name* Agency Name (if applicable) Relationship to Client* —SelfSpouseParentChildOther family memberCase workerAdvocateMedical providerOther Please specify: Phone* Email* Date of Referral* Client Information First Name* Last Name* Date of Birth* (Can be typed in by hand) Age Insurance* —NonePrivateMedicaid (You will be referred to a Medicaid Coordinator)MedicareCICPVAOther Please specify: Primary Phone* Email Physical Address Line 1* Physical Address Line 2 City* State* Zip Code* What are the immediate concerns and needs to be addressed?* Involved Parties Please list spouse, partners, agencies, and other supports that are involved with the client and family. Name Relationship Agency (if applicable) Email Phone If you get a message that says, “There was an error trying to send your message. Please try again later,” just click “Submit” again. If you continue to get an error message, or have any other questions please contact Amy Rowan at email@example.com or 970.614.7311 M-F 8-5 for assistance. Organizational Information Organization Name* Primary Phone* Primary Email* Volunteer Dates, Times, Numbers, and Work Descriptions Please provide the info below. If there are different shifts needed or different work requiring different volunteers to be done please complete 1 line item per shift/duty. Date Range (e.g. 4/2-4/16)* Time/Shift (e.g. 8am-10am)* # of Volunteers Needed* Description of Work (e.g. Help people load car)* Volunteer Skills and Criteria Please list any specific skills/criteria for the volunteers? (e.g. data entry, must be able to lift 20 lbs, at least 16 yrs old, etc.)* Location of Volunteer Work Street Address City State Zip Code If an address is not applicable, please specify the location here: Supervisor Information Supervisor Full Name (for the volunteers to check in with)* Supervisor Cell Phone* Supervisor Email* If you get a message that says, “There was an error trying to send your message. Please try again later,” just click “Submit” again. If you continue to get an error message, please contact 970.708.7096 M-F 8 -5 for assistance.