Referral Intake Form - Covenant Case Management Services

Disclaimer and Consent for Information Sharing

By completing this form, you acknowledge and agree that the information provided may contain Protected Health Information (PHI). Covenant Case Management Services will use this information solely for the purpose of care coordination, case management, and related support services.

We are committed to protecting your privacy in accordance with the Health Insurance Portability and Accountability Act (HIPAA). Any information shared with us will be kept confidential and only disclosed as permitted by law or with proper authorization.

By checking the box below, you confirm that you have read, understand, and agree to this disclaimer and consent to the collection and use of information as described.

Digital Agreement

I agree to the terms above

Care Coordinator

Please share some information about yourself.

Are you filling out this form on behalf of a client?

Yes

No

Your First Name

Your Last Name

Your Organization Name

MCO / Care Manager Email

Phone/Mobile

Client Information

Please share some information about the person you are referring.

Client First Name

Client Last Name

Email

Guardian (LPR)

Please upload the guardianship papers (if available | 5 file maximum limited to 10mb)

Choose File

MCO Record

Ethnicity

MID

Gender

Date of Birth

Hispanic / Latino

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Additional Information

Will staff be coming on with the client? (eg. They will need onboarding)

Yes

No

Staff Name

Staff Email Address

Staff Phone Number

Does the LRP require translation services?

Yes

No

Language

What is the client's funding source?

Please upload the 1915i eligibility.

Choose File

Please describe the funding source.

Where you referred by someone on the Covenant team?

Service Information

Where would you like the Supported Living service?

Specialized Consultative Services (SCS)

All the services below are part of the Specialized Consultative Service. Please select all those that apply.

PBSP/BCBA

Occupational Therapist

Physical Therapist

Speech / SLP

Recreation Therapy

Dietician / Nutritionist

Please upload SIS or NC-SNAP / Copy of Medicaid Card (if available)

Choose File

Medical Questionnaire

Please provide us with some medical information related to the client.

Primary Physician

Physician Email Address

Physician Phone Number

Preferred Hospital

Client Existing Conditions

Does the client have any of the following conditions?

Does the client currently take any medication?

Yes

No

Please list the medications that the client is currently on.

Does the client have a psychological evaluation?

Yes

No

File Upload

Choose File

Are there any other diagnoses that we should be aware of?

Does the client have any known allergies (medications, food, environmental)?

Yes

No

Please describe the allergies and their severity.

Additional Care Needs

Does the client have any additional care needs?