Program Referral Form

Services
Products
Employment
Contact

Services
Products
Employment
Contact

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)

Client Name(Required)

Date

MM slash DD slash YYYY

Intake Person(Required)

Phone Service

County(Required)

Do you have a home phone?(Required)

Yes

Home Phone(Required)

Do you have a cell phone?(Required)

Yes

Cell Phone(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Income(Required)

Smartphone?

Yes

Do you have wireless internet?

Yes

Age

Date of Birth

MM slash DD slash YYYY

Marital Status

Live Alone?

Yes

Nearest Relative

Relationship

Details

Have you fallen in the last 12 months? Number of falls?

1 - 2

3 -4

5 or More

Do you have any functional and/or mental limitations? ie: blindness, arthritis, dementia, etc.

No Limitations

1 - 2

3 or More

How many prescriptions and OTC medications do you take daily?

None

1 - 4

5 or More

Have you been admitted to the hospital within the last year? What were you admitted for? Emergency Admission?

1 - 2

3 - 4

More than 4

Emergency Admission?

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

1-2

3 or More

Do you live alone? Do you have family or friends that live near you? Do you have visitors regularly?

Lives with Family of Friends

Some Involvement with Family & Friends

Lives Alone with no Family

Do you receive other services? Such as skilled nursing, homemaking, meals on wheels, etc.

Limited Services

Several Services

Notes

Hidden

Score

CAPTCHA

Get in touch with a team member today!

Contact form

"*" indicates required fields

Name/Nombre*

Email/El correo electrónico*

Phone Number/Número de teléfono*

Message/Mensaje*

CAPTCHA

Contact Us

Grand Rapids Office

500 Cherry Street SE
Grand Rapids, MI 49503

(616) 454-8305

Holland Office

348 S. Waverly Rd., Suite 106
Holland, MI 49423
(616) 401-9140

On call 24 hours, 7 days a week

eldershelpers@eldershelpers.com

Program Referral Form

Connect with Us on Social

Facebook-f Youtube Google-plus-g

Our Services
Employment
Contact