Referring Person's Relationship to Individual
Name/Initials of Person Being Referred
County of Financial Responsibility
Location of Desired Placement
Need Accessible Home?
Level of Care Desired (adult foster care or supported apartments)
No guardian (own guardian)
Has a guardian - family member
Has a guardian - private/paid guardian
Describe any significant health issues (diabetes, TB, etc.), ambulation (walking) issues, or sensory issues (blind, deaf, etc)
Behavioral History - Please describe the behaviors that have presented a problem for the person, including the frequency and intensity. Include behaviors such as: physical aggression, verbal aggression, drug or alcohol abuse, sexual offending, med non-compliance, self harm, elopement from supervision, etc.
Is the person under civil commitment? Is the person on probation or parole? Please describe.
Does the person have a waiver - CADI, DD, BI, EW? If so, which one.
The waiver funds the program/staffing.
Name/Email of CADI Case Manager