Support Services Referral Form – Tri-County Health Network

The goal of our Individual Support Services programming is to provide community members the support they need to live their entire lives in their own homes. We focus on connecting clients with the resources that they need, with an emphasis on comfort, compassion, and dignity.

If you are in need of Care Coordination, ADRC Services or San Miguel County Palliative Support, or would like to make a referral on someone else’s behalf, please submit the form below and we will reach out to you to connect you with the appropriate support and services.

Verification of Client Consent

Is the client aware they are being referred?* YesNo

Has the client given verbal consent to discuss this information with other agencies?* YesNo

If you answered “No” to either of these questions, please inform the client and obtain verbal consent prior to proceeding.

Referring Contact/Agency Information

First Name*

Last Name*

Agency Name (if applicable)

Relationship to Client*

If other, please specify:

Phone*

Email*

Date of Referral*

Client Information

First Name*

Last Name*

Date of Birth* (Can be typed in by hand)

Gender*

If other, please specify:

Phone*

Living Arrangement*

If other, please specify:

Physical Address Line 1*

Physical Address Line 2

City*

State*

Zip Code*

Service Request Information

Services Requested* (Ctrl+Click to select multiple)

Please provide any additional information you feel is relevant to this request:

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 call Amy Rowan at (970.614.7311) M-F 8-5 for assistance.