*PLEASE NOTE: THIS REFERRAL FORM MUST BE COMPLETED IN ITS ENTIRETY IN ORDER FOR THE PARTICIPANT TO BE CONSIDERED FOR THE PROGRAM*
Important Notice: Due to the COVID-19 Pandemic, the demand on the products being made available through the Illinois CARE Connections Project is greater than the supply.
IATP anticipates several orders will have a delayed delivery of several weeks. Therefore, please understand that there may be a significant delay between when a referral was
entered and when the device bundle is actually shipped to the participant. Illinois CARE Connections will generate an email to the referring provider with the participant’s
name, UPS tracking number and date the device bundle is shipped.
Referring Agency Point of Contact
Please complete the information below for the participant:
(The participant is the individual for whom the device is being requested)
General Information: Potential participants must have a genuine interest in using the device to maintain and/or increase their
options for communication and social interactions with others. The referring provider must assess the potential participant using the UCLA-3 Item Loneliness Scale.
The three questions below measure three dimensions of loneliness: relational connectedness, social connectedness and self–perceived isolation.
The responses to the questions will be scored as follows:
|Some of the Time
The score for each individual question is tallied together to give you a possible range of scores from 3 to 9.
General Screening Questionnaire
Hardware, Software and Support
This program is funded by the Department of Health and Human Services, Administration for Community Living, Grant No. 90NWC30043-01-00