IHSS Referral

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 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 or email us at ihssintake@schsd.org. A Health Care Certification (HCC) is required to be completed and submitted to IHSS within 45 days of 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 needs assessment.

Client Information Información del Cliente

First Name

Last Name

Full Name

SSN

Date of Birth

Age

client is a minor

Gender

Language

Ethnicity

client currently has Medi-Cal

client is 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

IHSS Services Requested (check all that apply)

domestic tasks

personal care

transportation

paramedical services

protective supervision

Additional Contact Name

Relationship

Phone

Additional Information Información Adicional

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

Describe

Send CFCO Form MC 604

Referral from Adult & Aging Program

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

Sonoma County Human Services
In Home Supportive Services
IHSS Professional Referral Form

Client Information Información del Cliente

Household Composition (check all that apply)

IHSS Services Requested (check all that apply)

Physical Or Mental Conditions/Diagnosis

Primary Care Physician Médico de Atención Primaria

Primary and Additional Contact For Client

Additional Information Información Adicional

Referring Party Information Información de la parte remitente

Sonoma County Human Services In Home Supportive Services IHSS Professional Referral Form Formulario de Referencia Profesional de IHSS

Client Information Información del Cliente

Household Composition (check all that apply) Composición del Hogar (marque todas las que correspondan)

IHSS Services Requested (check all that apply) Servicios IHSS Solicitados (marque todas las que correspondan)

Physical Or Mental Conditions/Diagnosis Condiciones Físicas o Mentales/Diagnóstico

Primary Care Physician Médico de Atención Primaria

Primary and Additional Contact For Client Contacto Principal y Adicional Para el Cliente

Additional Information Información Adicional

Referring Party Information Información de la parte remitente

Sonoma County Human Services
In Home Supportive Services
IHSS Professional Referral Form

Household Composition (check all that apply)

IHSS Services Requested (check all that apply)

Physical Or Mental Conditions/Diagnosis

Primary and Additional Contact For Client