This secure referral information form will be routed to key Pathlight placement personnel. You will be sent an email requesting additional documents that will be used for prompt consideration. If you have any questions, please email *
Contact Information
Client Information
Does the client have a legal guardian?
Has client had issues maintaining a community placement before?
Will the client be able to visit for a placement assessment?
Is the client able to climb stairs?
Does the client use a wheelchair?
Does the client need ADL (Activities of Daily Living) assistance?
Is there a current behavioral plan in place?
Does the client require one on one or enhanced staffing?
Does the client have any medical restrictions surrounding food, such as diet/texture/consistency/calorie count?
Does the client have any history of (or current) substance abuse?
Does the client have Pica?
Does the client have any history of water intoxication?
Does the client have a history of fire-starting or suspicious fire related behavior?
Does the client have an Alternative Treatment Order (ATO) or Assisted Outpatient Treatment (AOT) program?
Would you consider an out of county placement with Pathlight Community Services?
Check any of the following the client is at risk for:

*While email is generally an unsecure form of communication, Pathlight Community Services is compliant with all HIPAA guidelines to ensure PHI (Protected Health Information) is kept secure through our mail servers.
All correspondence to a email account requires SMTP over TLS, which encrypts all data in transit to our mail servers (i.e. we do not accept plaintext email).
We have a BAA with our mail vendor to ensure all data is encrypted at rest under HIPAA guidelines.
In addition, all work devices are encrypted to provide the same at-rest encryption