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My mother's doctor needs this to certify the assistance of In-Home Supportive Services.

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The VA uses their own form 21-2680:
http://www.vba.va.gov/pubs/forms/VBA-21-2680-ARE.pdf
Your county social services may have their own form but certainly they would accept the federal form as a first step.
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I went to the Internet and typed in "In-Home Supportive Services" and many hits came up. Sounds like something used in California. You would need to check this out yourself depending on your situation.
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