*PLEASE NOTE: THIS REFERRAL FORM MUST BE COMPLETED IN ITS ENTIRETY IN ORDER FOR THE PARTICIPANT TO BE CONSIDERED FOR THE PROGRAM*

Requests can only be made by an authorized agency with a valid Agency Code

* = required

Referring Agency

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)
Is the participant new to your agency?  
Notice: The Device Bundle will be shipped via UPS with a signature required. Will the participant be able to sign for the package? *  
If no, is there an alternate address where the device can be shipped with signature requirement?    
Participant Receives services or supports via the following state agency: (check one or check all that apply)
CCP Participant?

OAS Participant?





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:
Response Score
Hardly Ever 1
Some of the Time 2
Often 3

The score for each individual question is tallied together to give you a possible range of scores from 3 to 9.

General Screening Questionaire

What is the main reason for participant being referred? (choose one)




Does the participant currently use a tablet type device?  
What kind of telephone does the participant use?  
Does the participant currently have Internet Access?  
Is there someone in the home or who otherwise is available to assist the participant with technical problems like resetting internet, rebooting or troubleshooting electronic equipment?  
Would the participant be able to participate in technical assistance via the following modalities: (check all that apply)


Functional Assessment

Paricipants Disability:

Cognitive/Memory – Will the participant be able to do sequential memory tasks for turning device on/off, navigating menus and activating applications (apps)?  
If no, how would you rate the participants’ cognitive/memory skills?      
Motor Skills/Dexterity – Will be able to find and manipulate buttons; can learn and perform gestures (i.e. tapping, swiping)?  
If no, how would you rate the participants’ motor/dexterity skills?      
Hearing – Will the participant be able to hear audio output of the device?  
If no, how would you rate the participants’ hearing/understanding speech?      
Vision – Will the participant be able to see and/or read the screen?

If unsure, how would you rate the participants’ vision/reading text skills?      

Hardware, Software and Support

Hardware

Hardware (please select one):

Accommodations

Possible Accommodations (check all that are needed):






This program is funded by the Department of Health and Human Services, Administration for Community Living, Grant No. 90NWC30043-01-00