Covenant Intake Form | Covenant Case Management Services

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Referral Intake Form

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Disclaimer
Care Coordinator
Client Information
Service Information
Medical Questionnaire
Additional Care Needs

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

First Name

Last Name

Organization Name

MCO / Care Manager Email

Phone/Mobile

Referral Date / Time

Client Information

Some description about this section

First Name

Last Name

Email

Guardian (LPR)

Please upload the guardianship papers (if available)

Choose File

MCO Record

Ethnicity

MID

Gender

Date of Birth

Hispanic / Latino

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Service Information

Please check all that apply.

Please select all the services that you are requesting.

Community Living & Support

Supported Employment

Day Support

Residential - Supported Living

Residential - Day Program

Respite

Community Networking

Long Term Community Supports

Nursing

Nursing Respite

Comprehensive Clinical Assessment (CCA)

IDD Psychological Testing/Eval.

Peer Support

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 provide a brief reason for the referral (if services are through 1915i)

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 describe the funding source.

Where you referred by someone on the Covenant team?

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?

Diabetes

Yes

No

What type of Diabetes does the client have?

G-Tube

Yes

No

Seizure Disorder

Yes

No

What type and how frequent are they?

Does the client currently take any medication?

Yes

No

Please list the medications that the client is currently on.

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?

Assistance with feeding?

Yes

No

Please explain

Communication needs?

Yes

No

Please explain

Mobility level/transfers challenges?

Yes

No

Please explain

Special dietary needs?

Yes

No

Please explain

Does the client have an emergency plan?

Yes

No

Please upload a copy of the plan.

Choose File

Assistance with toileting?

Yes

No

Please explain

Behavioural concerns?

Yes

No

Please explain

Sensory sensitivities (eg. light, noise etc.)?

Yes

No

Please explain

Advance directives (eg. DNR, living will, POA?

Yes

No

Please upload a copy of these directives.

Choose File

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Direct Support
Professionals

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Individuals Served
Since 2010

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Counties
Across NC

Covenant

Our purpose is to enrich lives and help individuals lead healthy, purpose-filled futures.

Phone: (704) 780-4552

Address: 421 W. Main Street
Albemarle, NC 28001-4641

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