Referral Forms

For consideration for the Children's Health Home Care Management program, please fill out and send in a referral form. Referral forms can be filled out by either a family member or a services provider on behalf of the child and family. Please be sure that the referral form is first reviewed for legibility, accuracy and completion prior to submission.

Completed referral forms can be faxed to 332-0956, emailed to, or mailed to:
Encompass Health Home
741 Delaware Avenue
Buffalo, NY 14209

Printable referral form

Fillable referral form