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Online Referral Form

Please complete the following form for Kent County Senior Millage (KCSM) and Older Americans Act (OAA) programs.

Program Referral Form

Please complete the following form for Kent County Senior Millage (KCSM) and Older Americans Act (OAA) programs.

What program(s) are you applying for?(Required)

KCSM - PERS

KCSM - Med Management

Both

OAA - PERS

Unsure

Date(Required)

MM slash DD slash YYYY

Referrer's Name(Required)

Referrer's Phone Number(Required)

Client Name(Required)

Client Phone Number(Required)

Client Address(Required)

Street Address Address Line 2 City State ZIP Code

Date of Birth(Required)

MM slash DD slash YYYY

Est. Monthly Income(Required)

Gender

Female

Male

Prefer not to say

Live Alone?

Yes

No

Emergency Contact

Phone Number

Physician's Name

Phone Number

How many falls have you had in the past year?

None

1 - 2

3 -4

5 or more

How many times have you been admitted to the hospital in the past year?

None

1 - 2

3 -4

5 or more

How many medications do you take daily?

None

1 - 4

5 or More

Do you have family and/or friends involved in your care?

No involvement

Some Involvement

Lots of involvement

Is it necessary for you to use any durable medical equipment? i.e. cane, walker, oxygen, etc.

No

1-2

3 or More

Do you receive other services? Such as homemaking/personal care, skilled nursing, home delivered meals, etc.

No Services

Limited Services

Several Services

Do you have any limitations? i.e. arthritis, blindness, etc.

No Limitations

1 - 2

3 or More

Please select the medical conditions you currently take meds for:

Cancer

Diabetes

Heart Disease

Hypertension

Alzheimer's/Dementia

Please list any notes or medical diagnosis

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Score

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