Adopt An Elder Referral Form

Referrer Name

Professional Role

Agency

Work Email

example@example.com

Work Phone

Please enter a valid phone number.Format: (000) 000-0000.

Relationship to the Referred Person

Older Adult Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

Approximate Age

Best Phone

Please enter a valid phone number.Format: (000) 000-0000.

Preferred Contact Method

Living Situation

Housing Situation

Safe Contact Instructions

Holiday need indicators

Reason for referral

What is the older adult's total monthly income before deductions?

Monthly income information is required to determine eligibility for the Adopt an Elder program. Please verify the income range with the older adult before submitting this referral.

Holiday Wish List Guidelines
Please work with the older adult to identify 3–5 holiday gifts or personal items that would bring comfort, joy, or practical assistance during the holiday season.

Wish lists may include clothing, pajamas, slippers, blankets, personal care products, household essentials, books, puzzles, hobby supplies, and other reasonably priced gifts. Grocery, pharmacy, and general merchandise gift cards are also welcome.

Nonperishable food and pantry essentials may be requested in addition to the 3–5 gift items. These may include canned goods, soups, pasta, rice, cereal, oatmeal, coffee, tea, and favorite shelf-stable snacks.

Please provide specific descriptions, clothing sizes, preferred colors, and other details that will help sponsors select appropriate items. Include any relevant food allergies or dietary preferences when requesting groceries.

To ensure requests remain appropriate for the program, please do not include cash, prescription medications, alcohol, tobacco products, weapons, or high-cost electronics.

Please note: All wish lists are reviewed by Circle of Care St. Louis. Requested items are subject to sponsor availability and cannot be guaranteed.

List 3–5 priority items requested by the older adult, including sizes and preferences

Are there additional practical items or special considerations a sponsor should know?

Priority essentials

Accessibility or delivery needs

Please confirm the older adult’s consent and review the information before submitting.

Confirmation

Confirmed agreement to holiday referral and sharing of information

Acknowledgment

Adopt an Elder Professional Referral Form

Referrer Information

Older Adult Information

Holiday Needs

Holiday Wish List Guidelines

Consent and Acknowledgment