Submit a Referral

Connect someone with non-medical support at home.

We welcome inquiries from families, service coordinators and community partners in Citrus Heights, Fair Oaks and the Sacramento area. Choose the support you are looking for below.

Individualized assistance

IDD Support

Refer a person with an intellectual or developmental disability for in-home assistance or respite. Include regional center and authorization details when available.

Start an IDD referral

Support at home

Veterans

For veterans, families and referral partners seeking non-medical help with daily routines, personal care and respite.

Start a veterans referral

Partner referrals

Community Supports

For health plans, care coordinators and members requesting non-medical in-home support. Plan participation and authorization must be confirmed.

Start a Community Supports referral

Start a referral

Share only information you are authorized to provide. This form is not monitored for emergencies; for urgent help, call 911. Questions? Call 279-782-1465.

Select a referral type above to begin.

About you

The person submitting this referral.

Full name

Please enter your name.

Please enter a valid email.

Phone

Please enter a phone number.

Your relationship to the person needing care

Please choose one.

Please describe

Please describe your relationship.

Organization, job title and team (optional)

About the person needing care

Full legal name

Please enter their name.

Date of birth

Please enter a date of birth.

Service address

Please enter the street address.

City

Required.

State

ZIP

5-digit ZIP.

Preferred language and any interpreter or communication support needed

Please enter a preferred language.

Their phone, email and preferred contact method, if different from the primary contact (optional)

Contacts

Who we should call to arrange care.

Primary contact

Full name

Required.

Relationship

Required.

Phone

Required.

Authorized representative or legal guardian: name, relationship, phone and email (if applicable)

Emergency contact: name, relationship and phone (optional)

Care needs

Requested services, care needs and reason for referral

Please describe the care needed.

Preferred start date, days and times, and estimated hours per week

Please add a schedule, or write "not yet known".

Help needed with bathing, dressing, toileting, meals, transfers, mobility, household tasks or reminders (optional)

Safety considerations: falls, wandering, behaviors, allergies, equipment, pets or home access (optional)

Diagnoses, disabilities or health conditions that affect non-medical care (optional)

Current services and providers (IHSS, home health, other in-home care), schedules and unmet needs (optional)

Current hospitalization or discharge plan, including expected discharge date and facility contact (if applicable)

Regional center and authorization

Fill in what you have and leave the rest blank. We confirm eligibility, authorization and staffing before services begin.

Regional center and service coordinator: name, phone, email and team (optional)

UCI number (7 digits, if assigned)

UCI numbers are 7 digits.

Requested IDD service (choose any)

Respite Personal assistance Housekeeping Other

Other service requested

Authorization status, service code, authorized hours or units, frequency and start/end dates (if available)

Does the client have a caregiver they'd like to use? If yes: name, phone, relationship and availability (optional)

Primary family caregiver and the relief or support they need (optional)

Support plan, behavior plan or authorization documents available for secure follow-up (list them; don't paste records)

Veteran care and VA coordination

Fill in what you have and leave the rest blank. Do not include a Social Security number or military records.

VA health care enrollment (optional)

Enrolled Not enrolled Not sure

VA medical center or clinic, and VA social worker or case manager: name, phone and email (optional)

What kind of care are you looking for? (choose any)

VA-authorized home care Private pay Respite Help understanding options

VA referral or authorization number, approved service, hours and start/end dates (if available)

Has care been authorized? If not, describe the referral status or help needed (optional)

Primary caregiver and the respite or support they need (optional)

Care preferences, including interest in a veteran caregiver (optional)

Authorization or care plan documents available for secure follow-up (list them; don't paste records)

Medi-Cal and Community Supports

Fill in what you have and leave the rest blank. Coverage, plan participation and authorization must be confirmed before care begins.

Medi-Cal managed care health plan (optional)

Medi-Cal CIN / member ID (if available)

Requested Community Support (choose any)

Personal care and homemaker services Respite Other

Other support requested

Referring health plan, ECM organization or community partner, and coordinator name, phone and email (optional)

Is the member receiving Enhanced Care Management or Community Health Worker support? If yes, list the organization and contact (optional)

Referral or authorization status, authorization number, approved service, hours/units and start/end dates (if available)

IHSS status, authorized hours, unmet needs and why additional support is requested (optional)

Primary caregiver and respite needs, if requesting respite (optional)

Health plan referral, authorization or assessment documents available for secure follow-up (list them; don't paste records)

Authorization

Please confirm before submitting.

Do not include Social Security numbers or payment card details. Responses go securely to our Google Workspace. Supporting documents can be arranged during follow-up.

Thank you, your referral was sent.

Our team will review it and contact you to discuss service fit, timing and next steps.

Need us sooner? Call 279-782-1465.

What happens next

1. Complete your referral

Choose a referral type and complete the form on this page. Provide contact details, care needs and available program or authorization information.

2. Discuss the care needs

We review the referral and contact you to discuss service fit, timing, payment options and next steps.

3. Confirm the plan

We confirm caregiver availability and required approvals before care begins. A referral does not guarantee coverage or eligibility.

Share only information you are authorized to provide. Referral responses are sent securely to our Google Workspace. Do not include Social Security numbers or payment card details. Supporting documents can be arranged during follow-up.

Prefer to call? 279-782-1465

Learn about our non-medical home care services or request a free care assessment.

Open a referral form directly: IDD | Veterans | Community Supports.

Submit a Referral

IDD Support

Veterans

Community Supports

Start a referral

Thank you, your referral was sent.

What happens next

1. Complete your referral

2. Discuss the care needs

3. Confirm the plan

Our care partners

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