Pro Action Yates Office for the Aging Referral Form

Pro Action Yates Office for the Aging Referral Form
Date:*

MonthDayYear
Date
Reason for Referral:*
Name:*
Email
example@example.com
Date of Birth:*

MonthDayYear
Date
Address:*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Referral Source:
Family Contact and Phone # (if needed):
Services Requested (check all that are needed):
Transportation ServicesHome Delivered MealsReducing Social Isolation/Increasing Social ConnectionsExercise&Wellness Programs: fall/prevention balanceExercise&Wellness Programs: strength & enduranceExercise&Wellness Programs: Bone HealthHousekeeping, personal care, shopping, laundry assistance (private hire list or sliding fee scale program)Case Management (must meet program eligibility criteria)Nutrition CounselingPersonal Emergency Response button to summons emergency assistance (monthly fee)Project Lifesaver-wandering locator device for those with cognitive impairment (monthly fee)
Assistance with Medicare, Medicaid and other insurancesInformation and counseling on long term care services and optionsPrograms to help stretch a fixed income to cover monthly billsLegal Services (Civil Only)
NY Connects- referral program for all ages for information regarding long term care choicesCaregiver Support Services, including support groupsRespite services for a loved one
All Services are provided to individuals 60 and older on a donation basis unless otherwise noted. Some services are available for individuals under 60, please inquire.
Should be Empty:

Pro Action Yates Office for the Aging Referral Form

Services Requested (check all that are needed):