Macomb County Senior Services Case Referral

Case Referral Submission Form

This is not an emergency referral source. If this is an emergency, please call 911.

This portal is intended to only be used by professionals who work with older adults. Suspected cases of abuse or neglect can be submitted through the HIPPA protected portal.

Appropriatec Cases should be submitted through the portal if they are experiencing barriers or gaps in services. Cases submitted through the Multidisciplinary Team (MDT) portal will be reviewed and discussed with the MDT to determine appropriate intervention.

Type Case Referral
CASE INFORMATION

Multidisciplinary Team (MDT)
MDT Referral Eligibility

Macomb County adult, 60 years or older, where there is suspicion of abuse, neglect, exploitation, self-neglect, or hoarding issues.
Form Name
Submission Date

MonthDayYear
Date
Name of Person Reporting:
Title and Organization (Person Reporting):
Person Reporting
Phone Number or Contact Information (Person Reporting):
Client/Victim Name:

First NameLast Name
Is there an open APS case?
Signed Release of Information and/or Other Documents:

*If there is verbal release, please fill out form and document verbal consent given. Signed ROI must be from your organization or a general release.
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Additional Notes and Summary or Immediate Concerns:
Case Information

Case Managment
Case Management Referral Eligibility
Submission Date

MonthDayYear
Date
Name of Person Reporting:
Title and Organization (Reporting Person):
Phone Number or Contact Information (Reporting Person):
Client/Victim Name:

First NameLast Name
Is this individual aware that a referral was made for them to Macomb County Office of Senior Services, Case Management?
Is there an open APS case?
If submitted to Case Management, would you also like to make a referral to the MDT Team?
Signed Release of Information and/or Other Documents:

*If there is verbal release, please fill out form and document verbal consent given. Signed ROI must be from your organization or a general release.
Cancelof
Additional Notes and Summary or Immediate Concerns:
The section below will be completed by the Elder Justice Alliance Coordinator
Completed by Elder Justice Coordinator:
Date Presented:

MonthDayYear
Date
MDT Case Number:
MDT Case Number (Completed by EJA Coordinator)
Client/Victim Initials:
Gender:
Age:
Is the client/victim willing to accept services/E-MDT intervention?:
Release of Information signed?
Signed Release of Information File Upload

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Informed Consent/Confidentiality Form Signed
Signed Informed Consent/Confidentiality File Upload

Cancelof
Living Arrangements:
Living Arrangements Other:
Ethnicity:
Ethnicity Other:
Special Classifications
Special Classifications Other:
Alleged Abuser:
Alleged Abuser Other:
Type (s) of alleged abuse/victimization :
Type (s) of alleged abuse/victimization other:
Previous History/Reports (describe):
Current Services/Interventions received:
Date:

MonthDayYear
Date
Documents (Risk Assessment, Safety Plan, Etc.)

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Additional MDT Meeting Review Notes:
Additional Case Management Notes:
Goals for this case: (Desired outcome as stated by the client)
Assignments and Follow Up
Needs Identified:
Agency Referring To:
POC: (Primary Contact Person(s))
Date of Referral:

MonthDayYear
Date
Agency Referring To:
POC: (Primary Contact Person(s))
Date of Referral:

MonthDayYear
Date
Agency Referring To:
POC: (Primary Contact Person(s))
Date of Referral:

MonthDayYear
Date
Additional Services/Specialists Required:
Comments/Notes:
Follow-Up/Response with the client/victim:
Outcome (Closing Summary):
E-MDT Coordinator:
Date:

MonthDayYear
Date
Should be Empty:

Case Referral Submission Form

This is not an emergency referral source. If this is an emergency, please call 911.

CASE INFORMATION

Case Information

The section below will be completed by the Elder Justice Alliance Coordinator

Completed by Elder Justice Coordinator:

Assignments and Follow Up