Eastern Area Agency on Aging referral form                                    
 

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Name of referring organization : 

Name of person referring : 

Phone number of referring person : 

Consumer name : 

Consumer DOB : 

Consumer Town of Residence : 

Contact person phone number : 

Should a Caregiver be contacted? 

Caregiver's Name 

Caregiver's Phone Number 
 ‚Äč
Referral needs.  Check all that apply :

Caregiver Information                              Meals on Wheels
Health insurance counseling                   3-D Catering
Home Safety Concerns                           EZ Fix Program                                     
Alzheimer's Information                           Nutrition Information
 Furry Friends                                          
Exercise Programs (including Tai Chi and Senior Strength)
 Volunteering                                           

Transportation                                         
Money Minders                                       
Food Insecurity Program            
Emergency Food Box Was Issued to Consumer   
Commodity Supplemental Food Program
Matter of Balance
Living Well

Meals on Wheels Eligibility (Check all that apply):

60+ years of age
 Homebound or isolated
 No reliable support system, Unable to prepare own meals
(2 or more of the following)
 
Doesn't understand how to prepare well-balanced meals
 Cannot access items in the cupboard, stove or refrigerator
 Endurance too low to prepare well-balanced meal & then eat
 Cannot turn stove or oven on and off due to physical limitations
 Cannot shop or obtain food adequate for preparing well-balanced meals
 Not in an Assisted Living where meals are served

Additional Information :

Electronic Signature :

The consumer consents to the referring provider and ADRC sharing information
specifically related to this referral :


Yes
No