Derivació – Centre de Vida Independent

Formulari derivació - Next Generation

*Nom del derivador

*Cognoms del derivador

*Mail

*Telèfon del derivador

*Servei derivant

*Nom del beneficiari

*Cognoms del beneficiari

NIF

Data naixement

*Telèfon

Nom i cognom del contacte del beneficiari

Número de telèfon del contacte

*Codi postal

Província

*Població

Districte

*Nom del carrer

*Número

*Pis i porta

Informació de l'habitatge

*Discapacitat

Grau de discapacitat

Servei d'atenció domicili (SAD)

*Dependència

Certificat de baixos recursos economics

Dificultats en Activitats de la Vida Diària (AVD) - (per seleccionar més d'una opció manté premut el botó de 'ctrl' o 'cmd' i selecciona)

Informació rellevant

Conductes disruptives

Deteriorament cognitiu

*Valoració professional

Privacy Overview

This website uses cookies to improve your experience while you navigate through the website. Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. We also use third-party cookies that help us analyze and understand how you use this website. These cookies will be stored in your browser only with your consent. You also have the option to opt-out of these cookies. But opting out of some of these cookies may affect your browsing experience.

Necessary

Sempre activat

Necessary cookies are absolutely essential for the website to function properly. These cookies ensure basic functionalities and security features of the website, anonymously.

Galeta	Durada	Descripció
cookielawinfo-checkbox-analytics	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Analytics".
cookielawinfo-checkbox-functional	11 months	The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional".
cookielawinfo-checkbox-necessary	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookies is used to store the user consent for the cookies in the category "Necessary".
cookielawinfo-checkbox-others	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Other.
cookielawinfo-checkbox-performance	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Performance".
viewed_cookie_policy	11 months	The cookie is set by the GDPR Cookie Consent plugin and is used to store whether or not user has consented to the use of cookies. It does not store any personal data.

Functional

Performance

Analytics

Others

Formulari derivació - Next Generation

Tu privacidad es importante