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Offering ACRC Families:
Fill out the following information and submit it electronically.
Once we receive the referral, our office will contact the family by sending out an application packet (EOR) or conducting an intake to assess the family's needs. (Full Service AR)
Who will be managing the Individual Served's care?
PHS will process up to two EOR Care Providers per family at no cost to the referred family. A $75 processing fee will apply for each additional EOR Care Provider requested within the same calendar year.
Please ensure that a separate referral is completed for each individual served
Please upload the Individual Served's IPP. If you are submitting a referral for Personal Assistence (PA), an IPP is required.
Is there a Behavior Intervention Specialist involved? If So:
Does the Individual Served require any rescue medications such as epi-pens, nebulizers or inhalers?
If yes, please list below he emergency medication(s) that may need to be administrated to the Invididual Served during respite in case of an emergency:
Please upload the doctor's note specifying that the selected care Provider for the Individual Served is qualified to administer such medications:
You will receive a copy of this referral when you submit.
