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Call: (415) 355-6700, extension 3, or email us at [ihss@sfgov.org](ihss@sfgov.org)  \nPlease answer all questions and print clearly  \nIHSS Applicant Date Sent: / /  \n\n| Last Name | First Name |  |  |  |  |  | MI |  | - -\u003Cbr>Social Security Number |  |  |  | / /\u003Cbr>Birth Date |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Street Address |  | Apt\\# |  | Zip |  |  |  |  | ( ) -Phone |  |  |  | Email |  |  |\n| What is your gender: (one that best describes your current gender identity)\u003Cbr> Male  Female  Trans Male  Trans Female  Genderqueer/Gender Non-binary Not listed. Please specify: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| How do you describe your sexual orientation or sexual identity?\u003Cbr>(indicate one that best describes your sexual orientation)\u003Cbr> Straight/Heterosexual  Bisexual  Gay/Lesbian/Same-Gender Loving  Questioning/Unsure  Not listed. Please specify:\u003Cbr> Decline to answer |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Ethnicity: |  |  |  | Language(s): |  |  |  |  |  |  |  |  |  |  |  |\n| Does applicant receive Supplement Security Income (SSI)? |  |  |  |  |  |  |  |  |  |  |  Yes\u003Cbr>|  No \u003Cbr>| Unknown |  |  |\n| Is the applicant enrolled in Medi-Cal? |  |  |  Yes\u003Cbr>|  |  |  No \u003Cbr>|  |  |  | Unknown Interest in CALFRESH? |  |  |  |  Yes \u003Cbr>| No |\n| If you have Medi-Cal, please indicate Medi-Cal /CIN \\#: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Does The client consent to IHSS services? \u003Cbr>|  |  |  |  | Yes \u003Cbr>|  |  | No; If not, please do not proceed with this application. |  |  |  |  |  |  |  |\n\nReferent Information  \n\n| Referent Name: |  | Relationship to Applicant: |\n| --- | --- | --- |\n| Phone: ( ) - | Ext: | Agency/Organization: |\n\nResidence/Discharge Information  \n\n| Living Situation: Lives Alone? Yes  No  Unknown Number of others in household: |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| Household members’ relationship to client:\u003Cbr> Spouse/Domestic Partner Adult Child Other Relative Non-relative |  |  |  |  |\n| The client is currently:\u003Cbr> At Home/At an Alternative Address\u003Cbr> Hospitalized – Target Discharge Date: / /\u003Cbr>Was client discharged from facility within the last 30 days?  Yes  No If yes, date: / / |  |  |  |  |\n| Hospital: | Campus/Site: | Room: | Bed: | Floor: |\n\nSpouse/Other IHSS Recipient  \n\n| Is the client married?  Yes  No  Unknown\u003Cbr>*If yes, please answer the following questions about the spouse (if in the home) . |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Last Name |  |  |  |  |  |  |  |  |  | MI |  |  | - -\u003Cbr>Social Security Number |  |  |  |  |  | / /\u003Cbr>Birth Date |  |\n|  | First Name |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Is the spouse an IHSS Recipient? \u003Cbr>|  |  |  |  | Yes \u003Cbr>|  |  | No |  |  |  | Unknown |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Is the spouse able to do housework?  Yes  No If no, why not? Spouse’s Doctor Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Name: |  |  |  |  | Address: |  |  |  |  |  |  |  |  |  |  |  |  | City: |  | Zip: |\n| Phone: ( ) - |  |  |  | Fax: ( ) - |  |  |  |  |  |  |  |  |  |  |  |  | Email: |  |  |  |\n| Other IHSS recipients in the household? |  |  |  |  |  |  | Yes |  |  |  | No |  |  |  | Unknown |  |  |  |  |  |\n| If yes, IHSS Recipient’s Name: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Social Security Number: - - |  |  |  |  |\n| Relation: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n\nForm 3012 (Rev. 05/24) Mail to: Department of Disability and Aging Services P.O BOX 7988 San Francisco, CA 94120 Page 1 of 3  \nOn-Call Home Care  \n\n| Is On-call home care requ","cbCaiacNoyG0D1kz","https://ap.wps.com/l/cbCaiacNoyG0D1kz","pdf",358406,"English","# Applicant Information\n## Gender and Sexual Orientation\n## Benefits and Program Eligibility\n# Referent Information\n# Residence and Discharge Information\n# Spouse/Other IHSS Recipient\n# On-Call Home Care\n# Applicant’s Physician/Clinic Information\n# Medical and/or Mental Health Information\n# Emergency Contact Information\n# Ability Assessment for Services","[{\"question\":\"What information does the IHSS referral form collect about the applicant?\",\"answer\":\"The form collects applicant personal details (name, address, phone, email), gender and sexual orientation, SSI and Medi-Cal status, CalFresh interest, and whether the client consents to IHSS services.\"},{\"question\":\"What referent and residence/discharge details are requested?\",\"answer\":\"It asks for referent name, relationship, and contact information, plus the applicant’s living situation, household composition, current status (at home, alternative address, hospitalized with target discharge date), and facility details when applicable.\"},{\"question\":\"How is on-call home care requested and what additional authorization is mentioned?\",\"answer\":\"The form includes whether on-call home care is requested and why it is needed, plus how needs will be met until eligibility is established. It states DAAS cannot authorize on-call IHSS services without a completed health care certification form SOC 873, which must be faxed to DAAS Intake.\"}]","In-Home Supportive Services Referral Form | PDF",1789836035]