MSSP/Linkages Referral

Sonoma County’s Adult & Aging Division offers case management programs to support the unique needs of older adults (60+) and people with disabilities of all ages. Each program has separate eligibility criteria and the length of involvement in the individual’s life varies. All programs offer support from an Adult & Aging Social Worker and Public Health Nurse to help qualifying Sonoma County residents live as safely and independently as possible in the community.

Upon completing the referral below, the information will be reviewed and screened by a social worker and program supervisor for two case management programs: Multipurpose Senior Service Program (MSSP) and Linkages Care Management. Both programs require that the referred individual, or designated support person be able to actively work with the program and oversee their own day-to-day needs. If the individual’s needs cannot be met by one of these two programs, the referred individual may be offered alternative community resources that could support them in other ways.

Referring Party Information

name		referral date
phone		fax
relationship
agency
	remember my details

Prospective Client Information

first name		last name
SSN		DOB	Age
location	unhoused resides at the following address owns home
address
city
state	AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY zip
phone		language	--- Select --- English Spanish Arabic Armenian ASL Cambodian Cantonese Farsi French Hebrew Hmong Ilocano Italian Japanese Korean Lao Mandarin Mien Polish Portuguese Russian Samoan Tagalog Thai Turkish Vietnamese Other Unknown interpreter needed
marital status	--- Select --- Single Married Divorced Widowed Cohabitating Civil Union Domestic Partners Unmarried Partners Unknown	partner
gender	--- Select --- Male Female Transgender Male Transgender Female Non-Binary Other Unknown	pronouns	--- Select --- She/Her He/Him They/Them Other
on premises	smokers dogs firearms other
	client has regular paid caregiver		IHSS recipient
IHSS social worker
healthcare	Medicare Medi-Cal w/share of cost
Health Provider	--- Select --- Kaiser Alexander Valley Healthcare Alliance Medical Center Petaluma/Rohnert Park Health Centers Brookwood Heath Center Jewish Community Free Clinic Santa Rosa Community Health Center at Lombardi Sonoma County Indian Health Project, Inc. Vista Family Health Center Sonoma Valley Community Health Center West County Health Centers Santa Rosa VA St Josephs The Grove Other	Kaiser # Doctor Other Health Provider
contact	client directly another person	name
		phone
		language	--- Select --- English Spanish Arabic Armenian ASL Cambodian Cantonese Farsi French Hebrew Hmong Ilocano Italian Japanese Korean Lao Mandarin Mien Polish Portuguese Russian Samoan Tagalog Thai Turkish Vietnamese Other Unknown interpreter needed
	client is aware of referral

Participation Readiness Assessment

The client is able and willing to help identify their own needs and participate in care planning.

not at all/unlikely

somewhat

mostly/definitely

---

The client has a committed support person to participate and follow up with care planning and steps to meet their goals.

not at all/unlikely

somewhat

mostly/definitely

---

Additional Information

Informal Supports

name		phone
relationship		contact frequency
quality of relationship
name		phone
relationship		contact frequency
quality of relationship

Needs Assessment

reason for referral
goals client wants to address
health issues affecting client's ability to live independently	exists does not exist not applicable
unmet ADL/IADL client needs	exists does not exist not applicable
recent life changes/events	exists does not exist not applicable
Additional Areas of Concern	emotional health cognitive functioning challenging behaviors other
Describe
client strengths, values and interests
any additional comments