Macomb County Senior Services Case Referral

Type Case Referral*

Multidisciplinary Team (MDT) Case ReferralCase Management Referral (Nonemergent Only)
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?*

YesNo
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:
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?

YesNoUnknown
Is there an open APS case?*

YesNo
If submitted to Case Management, would you also like to make a referral to the MDT Team?

YesNo
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?:

YesNo
Release of Information signed?

YesNo
Signed Release of Information File Upload

Cancelof
Informed Consent/Confidentiality Form Signed

YesNo
Signed Informed Consent/Confidentiality File Upload

Cancelof
Living Arrangements:

AloneWith spouseWith friendsWith familyNursing/Care facilityWith perpetratorShelterOther
Living Arrangements Other:
Ethnicity:

American IndianAlaskan NativeAsianAfrican AmericanHispanic/LatinoNative Hawaiian/Pacific IslanderCaucasianOther
Ethnicity Other:
Special Classifications

VeteranDisabled (Physical, Cognitive, Developmental)HomelessnessDeaf, deafblind, hard of hearingDiminished CognitionHomeboundSubstance AbuseLGBTQLanguage BarriersBlind, legally blindOther:
Special Classifications Other:
Alleged Abuser:

Family MemberAcquaintance/FriendOtherN/A
Alleged Abuser Other:
Type (s) of alleged abuse/victimization :

Adult physicalAdult sexualAdults sexually abused/assaulted as childrenArsonBurglaryCyber CrimesDIU/DWIDomestic/Family violenceElder Abuse or NeglectFinancial ExploitationGang violenceHate CrimeHoardingIdentity Theft/fraudMass violenceOtherOther vehicular (hit and run)RobberySelf-neglectStalking/harassmentSurvivors of homicide victimsTerrorism (domestic/international)Theft FinancialTheft MedicationsTheft Property
Type (s) of alleged abuse/victimization other:
Previous History/Reports (describe):
Current Services/Interventions received:
Date:

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

Cancelof
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:

HousingMedical Coordination/BenefitsConservatorshipGuardianshipReferral for Mental HealthFoodTransportationCommunity SupportsCounseling ServicesUtility AssistanceBudgetPeer GroupsVolunteer GroupsPhysical Safety in the home (ex. fall risk)Safety in the home (ex. abuse, assault, neglect, etc.)Other
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 INFORMATION

Case Information

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

Completed by Elder Justice Coordinator:

Assignments and Follow Up