Referral Worksheet

Decide whether to pursue an HES referral

Answer a few questions about the person — role, region, living situation, goals, and concerns. In about two minutes you get one of three clear recommendations: primary, secondary, or stop.

When to use it

Before a Life Plan meeting, to know whether HES belongs in the discussion.
When a family asks "is this for us?" and you want a structured answer.
As an intake step when onboarding a new participant.

Open the web form Download the PDF form

Both versions ask the same questions and score the same way. The web form runs in your browser — nothing you enter is sent or saved anywhere. The PDF is two pages, made for printing.