Online IHSS Application Form

County of San Luis Obispo Residents In Home Supportive Services Client Referral

Complete all mandatory fields. Required fields contain an asterisk (*)
Once referral is submitted you will be contacted regarding your request for IHSS Services

SLO County Residents IHSS Client Referral

Community Partner/Company Referring Client:
Person Referring Client:	Full Name of Person Referring Client
Phone number:	( ) - Second three digits Last four digits Phone number of Community Partner Referring Client
Applicant Information
First Name*:
Middle Name:
Last Name*:
Date of Birth:	Today
Language*:
Residence Address:
City*:
State*:
Phone number*:	( ) - Second three digits Last four digits
Best time to reach you between Monday-Friday 8am-5pm*:
Currently on Hospice?:	Yes No
Physician Name:
Known Medical Conditions? :	Describe all known medical conditions / diagnoses
Comments:
Authorized Representative
Does the applicant have/need an Authorized Representative?: Yes No
Authorized Rep Name:
Authorized Rep phone:	( ) - Second three digits Last four digits

Child Hotline Information:

If you suspect there is an emergency requiring immediate intervention, call 911
To report suspected child abuse or neglect call the 24 hour Child Abuse Hotline at (805) 781-KIDS (5437) or toll free 1-800-834-KIDS (5437)

Adult Hotline Information:

If you suspect there is an emergency requiring immediate intervention, call 911
To report suspected elder abuse or neglect call the Adult Services Hotline at (805) 781-1790 during regular business hours, or after business hours call (844) 729-8011
Mandated Reporter