Sonoma County Human Services Department
Adult & Aging Services Division
IN-HOME SUPPORTIVE SERVICES
The office is open Monday— Friday from 8 am to 5 pm.

To submit a referral, complete all of the sections below. All of the fields are required in order for IHSS to proceed with a referral. If you do not have all of the information or if you or your client want to follow up with the status of an application, contact our office by calling 707-565-5900. A Health Care Certification (HCC) is required to be completed and submitted to IHSS within 45 days from the IHSS referral. IHSS cannot move forward with the referral until a completed HCC has been received. Once the HCC is received and Medi-Cal is established, an IHSS Social Worker will contact your client to schedule a home visit where they will complete an IHSS assessment.

IHSS Professional Referral Form

Client Information

*First Name:		*Last Name:
*Mailing Address:
*City:
*State:		*Zip:

Click here if the Residence Address is the same as the Mailing Address.
*Residence Address:
*City:
*State:		*Zip:

*Phone:		E-Mail:
**Social Security #:		*Date Of Birth:
** If you do not have the client’s SSN, do not submit an online referral. You can either complete the online referral once you have this information or contact IHSS Intake by phone at 565-5900.
*Gender:		*Language:
*Ethnicity:
Client currently has Medi-cal
Client aware that a referral is being made on their behalf

*Household Composition (check all that apply)

Lives alone	Married	Other IHSS recipients in household
Lives with others	(if so, how many?):

*IHSS Services Requested (check all that apply)

Domestic Tasks	Personal Care	Transportation
Paramedical Services	Protective Supervision

*Physical or Mental Conditions/Diagnosis

Primary Care Physician

*Physician Name:
*Clinic Name:
*Phone:

Primary and/or Additional Conact for Client

*Contact Name:		Contact Name 2:
*Relationship:		Relationship:
*Phone:		Phone:

Additional Information

(Please include any details regarding the Client's health status, family dynamics, or safety concerns.)

Referring Party Information

*Full Name:
*Title:
*Email:
*Phone:

* Required fields.

Upon clicking the "Submit" button, a Healthcare Certification form download link will be sent to your
browser where you can save and print it.

IHSS Professional Referral Form

What is IHSS?