ANU Community Development — Patient & Family Referral Form
Thank you for taking the time to submit a referral to ANU Community Development Corporation. We are a 501(c)(3) nonprofit organization serving Metro Atlanta, dedicated to supporting seniors, caregivers, veterans, and families navigating life's hardest moments. This form is open to everyone — family members, doctors, social workers, case managers, and community members are all welcome to refer. You do not need to be a medical professional to submit. If you are unsure whether someone qualifies, submit anyway — we will follow up and help connect them with the right resources. Once we receive your referral, a member of the ANU team will reach out within 2–3 business days. If the need is urgent, please visit our website at anucommunitydevelopment.com to find the best way to reach us. Every referral is handled with confidentiality, compassion, and care.
About the person being referred
Full name of person being referred
*
Age or date of birth
*
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
example@example.com
City and ZIP code
*
Primary language spoken
Please Select
English
Spanish
French
Other — please specify
Type of support needed
What area of support does this person need?
*
Please Select
Caregiver support (Alzheimer's, dementia, aging-in-place)
Senior support and resources
Veterans housing and benefits
Food or childcare assistance
Transportation assistance
Financial counseling or housing stability
Eviction or foreclosure support
Life after bankruptcy
Crown of Confidence — medical wig program
Other — please describe below
Please briefly describe the situation
How urgent is this referral?
*
Not urgent — within the next few weeks
Somewhat urgent — within the next few days
Very urgent — needs help as soon as possible
About you — the person referring
Your full name
*
Your relationship to the person being referred
*
Please Select
Family member
Doctor or nurse
Social worker
Case manager
Community member or neighbor
Other — please specify
Your phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your email address
*
example@example.com
Does the person being referred know they are being referred?
*
Yes — they know and have given permission
No — I am referring on their behalf
They are referring themselves
Consent and submission
I give ANU Community Development permission to contact the person listed above using the information provided.
*
I confirm that the information I have provided is accurate to the best of my knowledge.
*
Additional Comments or Special Requirements
Submit referral
Should be Empty: