Project Lifesaver Participant Referral Form
Referral Source
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City of Los Angeles
WDACS Social Worker
Other
Kaiser Permanente
Other Referral Source
Agency Name
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Alzheimer's Greater Los Angeles
St. Barnabas Senior Services Los Angeles
Special Service for Groups - S.I.L.V.E.R.
Reporter First Name
Reporter Last Name
Reporter Email
APS Case No
Does the participant suffer from
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Alzheimers
Autism
Dementia
Other
Other Cognitive Impairment
Is the participant mobile, prone to wandering and is an LA County Resident?
Yes
No
Is the Authorized Agent or Caregiver aware you are submitting a referral on their behalf to the LA Found Program?
Yes
No
Participant Information
First Name
Last Name
Date of Birth
Home Address
City
Zip Code
Home/Cell Phone No
Is the participant mailing address same as home address
Yes
No
Mailing Address
Email
Language Spoken at Home
select an option
English
Spanish
Armenian
Chinese
Farsi
Hindhi
Japanese
Khmer/Cambodian
Korean
Russian
Tagalog/Filipino
Thai
Vietnamese
Other
Other Language
Comments
Authorized Agent
First Name
Last Name
Home Address
City
Zip Code
Home/Cell Phone No
Email
Is the authorized agent mailing address same as home address
Yes
No
Mailing Address
Relationship to Applicant
Preferred method of contact
select an option
Email
Phone
Mail
SUBMIT