How Can We Help You? Intake

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Who are you contacting us for?* This field is required.If you are reaching out regarding someone else, we will contact you directly. Privacy requirements may limit what we can discuss, but we can provide general guidance.
For myself
For a family member, friend, or other person
For a client/patient
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For professionals: This form is not a referral or formal service authorization form. If you are contacting us about a patient/client, please do not submit confidential medical information unless specifically requested. The individual may need to participate in contacting the ADRC or give permission for us to contact them.

You may find our Resource Guide helpful, or our Meals on Wheels referral form.

Click "Next" to continue with this form.
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Agency or Clinic/HospitalIf you are completing this form regarding someone else, please enter the name of your agency here
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Inquiring Person: What is your name?* This field is required.If you are completing this form regarding someone else, please enter your name here
First and last name
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How do you prefer to be contacted?
Call me in the morning (before noon)
Call me in the afternoon
Email me
Any way works for me
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Inquiring Person: Phone Number* This field is required.
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Inquiring Person: Email
example@example.com
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Name* This field is required.of person the inquiry is regarding
First Name
Last Name
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Address* This field is required.of person the inquiry is regarding
Line 1
Please Select
Please Select
Boyd, WI 54726
Bloomer, WI 54724
Cadott, WI 54727
Colfax, WI 54730
Cornell, WI 54732
Chippewa Falls, WI 54729
Holcombe, WI 54745
Jim Falls, WI 54748
City, State, Zip (scroll to see all options)
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Emailof person the inquiry is regarding
example@example.com
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Phone Number* This field is required.of person the inquiry is regarding
Please enter a valid phone number.
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To better help you, what information are you looking for?* This field is required.
Senior Farmers Market Vouchers
Public programs/assistance (Medicaid, BadgerCare, Foodshare, Energy Assistance)
Assisted living, nursing home, or options to safely remain at home (including long term care programs)
Social Security (SSI, SSDI) help
Medicare (or other insurance) help
Meals on Wheels, Senior Dining
Transportation Program for seniors
General help & resources (housing resources, pantries, medical equipment loan-closet, transportation options, etc)
I'm unsure / Other
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Age groupThis information helps us route you to the correct staff
17.5 to 59
60 or over
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Optional: Brief summary of your specific questions
Tip: Keep it short. We will connect with you to get full details.
0/400
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Date
Date
Month
Day
Year
Should be Empty: