Client Referral Form

PO BOX 647
JACKSONVILLE, AR 72078

CLIENT INFORMATION

Last Name *

First Name *

Middle Name

Date of Birth * 🛈

Race *

Gender *

Street Address *

Address Line 2

City *

State *

Zip Code *

County *

Phone Number *

Medicaid # *

Medicare

Guardianship *

Date of Last Psychological Test *

Psychological Testing upload

Has GED or High School Diploma *

Medications *

Medication List

List medications

List allergies:

Barriers or Limitations *

List other barriers or limitations

Checking or Saving Account

Amount of Assets

Social Security Benefits

Supplemental Security Income (SSI) amount

Diagnosis: *

Lived independently prior to this application

Social skills *

Behavior Concerns *

Medical concerns: *

Abilities/Strengths: *

Medical Information Upload

Reason for referral: *

Contact Person or Responsible Party Information

Last Name *

First Name *

Middle

Street Address *

Address Line 2

City *

State *

Zip Code *

County *

Phone Number *

Relationship to applicant *

Email Address *

How did you learn about Pathfinder? *

CURRENT/PRIOR COMMUNITY SERVICES: Please list locations.

WORKSHOP/EMPLOYMENT (ADDT)

LOCATION OF SERVICE

HOME & COMMUNITY BASED SERVICES (HCBS)

LOCATION OF SERVICE

PRESCHOOL/EDUCATION

LOCATION OF SERVICE

THERAPY SP-OCC-PHYS

LOCATION OF SERVICE

RESIDENTIAL

LOCATION OF SERVICE

OTHER

LOCATION OF SERVICE

Please check all areas of interest.

ADULT DEVELOPMENT PROGRAMS

BENTON WORKSHOP-BENTON, AR	JONESBORO WORKSHOP-JONESBORO, AR
BOONE COUNTY SPECIAL SERVICES-HARRISON, AR	PICKENS WORKSHOP-JACKSONVILLE, AR
NORTHWEST ARK WORKSHOP-ROGERS, AR	IWAC-JACKSONVILLE, AR

HOME & COMMUNITY BASED SERVICES

CENTRAL ARKANSAS

NORTHWEST ARKANSAS

NORTH CENTRAL ARKANSAS

NORTHEAST ARKANSAS

INTERMEDIATE CARE FACILITIES/IID

PRESCHOOL SERVICES

PATHFINDER PRE-SCHOOL, JACKSONVILLE, AR

HEART OF THE OZARK CHILD DEVELOPMENT CENTER, HARRISON, AR

RESIDENTIAL WITH DHS APPROVED MEDICAID WAIVER

PLEASE INSURE ALL ITEMS ARE CORRECT, THEN CLICK SUBMIT ONCE.

BRIARWOOD-BATESVILLE, AR	COTTONWOOD-MORRILTON, AR (Female Only)
DOGWOOD-JONESBORO, AR	EASTWOOD-WEST MEMPHIS, AR
GORDON TUBBS-CABOT, AR	LONGWOOD-SEARCY, AR (Male Only)
MCCREIGHT MEMORIAL, JACKSONVILLE, AR	PINEWOOD-BRYANT, AR (Male Only)
WESTWOOD-WEST MEMPHIS, AR (Male Only)	WHIT DAVIS-JACKSONVILLE, AR (Female Only)

BAMBURG-SEARCY, AR	CAVE SPRINGS, AR
GATEWAY-CABOT, AR	HOWELL-JACKSONVILLE, AR
JOHNSON-JACKSONVILLE, AR	MEADOWS-BRYANT, AR
OBRIEN-JACKSONVILLE, AR	PLAZA-JACKSONVILLE, AR
T.P. WHITE-HASKELL, AR	ZUMWALT COURTS-JACKSONVILLE, AR