PEAS Referral Form

Prevention & Early Access for Seniors Program (PEAS)

REFERRAL FORM
CLIENT INFORMATION
Client's Name*
Phone Number*
Address*
Date of Birth*

MONTHDAYYEAR
Age*
Gender*

MaleFemaleNon-binaryOtherPrefer Not to Say
Is the client part of the LGBTQIA+ Community?

YesNoOtherUnknownPrefer Not to Say
Race / Ethnicity*

CaucasianHispanic / LatinoBlack / African AmericanNative American / American Indian / Indigenous / Alaska NativeAsianNative Hawaiian / Pacific IslanderOtherUnknownPrefer Not to Say
Preferred Language*

EnglishSpanishOther
Emergency Contact
Emergency Contact's Phone Number
Relationship to Client
REFERRAL INFORMATION
Referrer's Name*
Agency
Email Address
Phone Number*
Relationship to Client
Reason for Referral*
Risk Urgency Level*

HighModerateLow
Reason for Urgency Level
Is the client aware of this referral?*

YesNo
Do you wish to remain anonymous?*

YesNo
Choice in Aging's Prevention & Early Access to Seniors (PEAS) program provides free and confidential therapy for Solano County residents 60 years of age and older. Seniors can receive up to 10 sessions with a Licensed Clinical Social Worker (LCSW) by phone, video, or in-home visits. This program is designed for individuals experiencing mild to moderate mental health symptoms, helping to support wellness and reduce stress.
Would the client be interested in receiving clinical/psychotherapy services?*

YesNo
Is there anything else we should know?
How did you hear about this program?

Gatekeeper TrainingPrint MediaSocial MediaWord of MouthOther
I understand that this is a referral form, and services are not guaranteed. A Choice in Aging staff member will contact the client to review the referral and determine eligibility.
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Prevention & Early Access for Seniors Program (PEAS)