DDS Referral Form

Fast. Flexible. Family Friendly

Thank you for choosing A1 Care for your home care support.

We offer rapid onboarding and audit-ready documentation. To refer someone, please fill out the form below. We confirm receipt within 2 business hours and can begin services within 48 hours of completed intake and authorization.

Contact Information

First name

Last name

Phone

Address

Birthday

Month

Day

Year

DDS ID (If Available)

Preferred Language (s)

Care and Need Preferences

Service Requested

Additional Comments

Living Situation

Emergency Contact Information

Referring Coordinator Information

First and Last Name

Phone

By submitting this form, I confirm that I have obtained the client’s or their legal guardian’s consent to share their information with A1 Care for the purpose of arranging services.