Ihss Referral FormFill Out and Use This PDF 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the IHSS Applicant section. Enter the applicant's last name, first name, middle initial, and contact information including street address, zip code, phone number, and email.
3. Indicate the applicant's gender identity and sex at birth. Provide details about sexual orientation and ethnicity as required.
4. Complete the Referent Information section if applicable. Include the referent's name, relationship to the applicant, and agency details.
5. In the Residence/Discharge Information section, specify living situation details such as whether the applicant lives alone and their current status (e.g., at home or hospitalized).
6. Fill out emergency contact information and provide any medical or mental health information relevant to the application.
7. Finally, review all sections for completeness before submitting your form through our platform.

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