Referral – Long Cheng Senior Center

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920-364-9323
info@longchengsc.com
1804 S. Lawe St Appleton, WI 54915

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Home
About
- Our Mission & Care Philosophy
- Licensing & Compliance
Services
For Partners
- Referrals & Intake
- MCO / ADRC Information
Contact Us

Home
About
- Our Mission & Care Philosophy
- Licensing & Compliance
Services
For Partners
- Referrals & Intake
- MCO / ADRC Information
Contact Us

REFERRALS & INTAKE

(Adult Day Care • Supportive Home Care • SMV Transportation)

Make a Referral

We accept referrals for:

Adult Day Care
Supportive Home Care
SMV Transportation

A team member will follow up to confirm eligibility, coordinate authorization, and schedule next steps.

Please fill out the form below

SECTION 1: REFERRAL SOURCE INFORMATION

Privacy Notice: Information submitted through this form may include protected health information (PHI) and is handled in accordance with HIPAA privacy and security standards. Access is limited to authorized personnel for care coordination purposes only.

Referral Type (check one):

Managed Care Organization (MCO)

Aging & Disability Resource Center (ADRC)

Hospital / Discharge Planner

Care Manager / Social Worker

Family / Self-Referral

Other

Other

If you selected "Other", please specify

Referring Organization:

Referring Staff Name:

Title / Role:

Phone:

Email:

SECTION 2: PARTICIPANT INFORMATION

Participant Name:

First Last

Date of birth:

Age:

Primary Language:

Hmong

English

Other

Other language

If you selected "Other", please specify:

Home Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone:

Emergency Contact:

Emergency Contact Phone:

SECTION 3: PROGRAM(S) REQUESTED

Programs

(Check all that apply)

Adult Day Care

Supportive Home Care

SMV Transportation (Specialized Medical Vehicle)

If SMV Transportation is requested, please indicate purpose:

Medical appointments

Adult Day Care transportation

Essential services (pharmacy, benefits appointments, etc.)

SECTION 4: FUNDING & ELIGIBILITY INFORMATION

Program Enrollment (if known):

Family Care

Partnership

PACE

ADRC Pending

Private Pay

Unknown / To Be Determined

Care Manager Name (if applicable):

Care Manager Phone:

Care Manager Email:

SECTION 5: PARTICIPANT NEEDS & CONSIDERATIONS

Needs and Considerations:

Supervision during the day

Assistance with activities of daily living

Social engagement / isolation reduction

Caregiver relief

Transportation support

Language-accessible services

Cultural considerations

(Check all that apply)

Mobility

Ambulatory

Uses walker

Uses wheelchair

Requires assistance with transfers

Any safety, behavioral, or medical considerations we should be aware of?

SECTION 6: REQUESTED START TIMEFRAME

Timeframe

As soon as possible

Within 1–2 weeks

Within 30 days

Flexible

SECTION 7: CONSENT & AUTHORIZATION

I authorize Long Cheng Senior Center to contact me and/or the participant listed above to discuss eligibility, services, and next steps.

Consent

I consent to being contacted.

By checking "YES" below, I acknowlege that I consent and understand a member of Long Cheng Senior Center will contact me.

Name

First Last

Date

Signature

Get In Touch

Email: info@longchengsc.com
1804 S. Lawe St Appleton, WI 54915
Phone: (920)364-9323

Long Cheng Senior Center provides culturally responsive Adult Day Care, Supportive Home Care, and SMV Transportation for Hmong elders. Services support aging in place through coordinated, non-medical care. Referrals accepted through ADRC and MCO care teams.

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