Assignment 4

[Agency logo and address]

Burlington Community Services

585 Plain Street

Sophia, NJ 01550

230-545-0105 Ext #1234

230-545-0102 Fax

December 01, 2011

[Name and agency affiliation of recipient]

Ms. Joyce M. Fuller, RN

Director of Patient Services

Sophia Visiting Nurse Association

585 Plain Street

Sophia, NJ 01550

Re: Request for home health-aide services for Ms. Georgia Vakrasis

Dear Ms. Fuller;

I am writing on behalf of my client, Ms. Georgia Vakrasis, to request home services to support her in her recovery period from [insert description of relevant health problem(s)].

Ms. Vakrasis, who is 60 years of age, lives alone at [address]. She has significant physical and emotional challenges and will be in need of more intensive post-surgery services after her hospital discharge on [date]. She will need the following services pending physician approval and your evaluation: home nursing visits; social work services [to support follow-up psychiatric evaluation]; home-health aide.

I have attached here her signed consent for services and for permission to share her medical and psychological evaluations and treatment. Her psychosocial history and medical/psychological treatment summaries are attached for your perusal and records.

I will call you on [date] to arrange for a telephone consultation with the agency representative who will coordinate services for Ms. Vakrasis.

Thank you, and I look forward to working with you to determine how to support Ms. Vakrasis in her recovery period.

Cordially,

Cynthia B. Foras

Case Manager

Day Treatment Center

Burlington Community Services

Sophia, NJ 01550