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IHSS Applicant Referral Form

  1. Once this referral form is submitted, you will receive a follow-up phone call to collect additional information and provide education about the IHSS program.  If you do not receive a call within 2 business days, please call our IHSS intake line at 707-253-6272.  Thank you!

  2. Who is making the referral?*
  3. What is the applicant's first and last name?
  4. What is the applicant's telephone number?
  5. What is the applicant's physical address?
  6. If the applicant's mailing address differs from their physical address, please include the mailing address below.
  7. Leave This Blank:

  8. This field is not part of the form submission.