Catawba Area Agency on Aging Pre-Screening Form for Services
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Number in household
*
What services are you interested in?
*
Home-Delivered Meals- Nutritious meals and nutrition education for older adults who do not drive and are unable to prepare meals due to illness, disability, or geographic isolation.
Group Dining Meals – Healthy meals and opportunities for social connection at nutrition sites and senior centers located in your community. Transportation to nutrition sites is provided if needed.
Homemaker Services – Assistance with light housekeeping to help maintain a safe and comfortable living environment.
Consumer Choice Home care – An extension of the homemaker program that allows individuals to choose the company providing their housekeeping services.
Consumer Choice Transportation – Transportation to medical appointments, with the freedom to select the provider you prefer.
Health & Wellness Programs – Evidence-based programs that promote healthy lifestyles and positive behaviors. These classes can improve daily function, support better health outcomes, and reduce hospital or emergency room visits. Programs are offered at senior centers or virtually for in-home participation.
What services are you currently receiving?
*
SNAP
Caregiver Grant
Medicaid Benefits
V.A. Benefits
Medicare Benefits
CLTC
None
Support Contact Name
*
First Name
Last Name
Support Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Support Contact Zipcode
*
Do you drive?
Please Select
Yes
No
Submit
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