Professional Request Form

Senior Services’ Help Line provides information and referrals to older adults, 60 years of age or older, in Forsyth County, NC and their caregivers.

So that Help Line can best assist you, as a local professional, please complete the following form as completely as possible. Help Line will make every effort to respond to your request within one business day. The response will come from helpline@seniorservicesinc.org. If you have not heard from Help Line within 1 business day, please check your email's spam or junk folder to avoid a missed response.

If you have any questions please contact Senior Services’ Help Line at 336-724-2040 or email helpline@seniorservicesinc.org.

Please check what you are seeking Help Line's assistance with: *

Request information and referral list(s)

Refer my client/patient directly to a community partner(s)

Both

Client/patient lives in Forsyth County. (If not, please contact that county's Senior Services.) *

Yes

Professional Contact Information

Please fill this information out about yourself, as the professional making the referral.

First name *

Last name: *

Agency: *

Title: *

Department/Program

Email: *

Phone: *

Ext:

Client/Patient Information

Please fill this information out about the client/patient you are serving.

First Name *

Last Name *

Please check: *

Male

Female

Phone Number *

Street Address *

Address Line 2

City *

State *

Zip Code *

Email Address

Marital Status: *

Date of Birth +

Age *

Additional Information About Client/Patient

Please note eligibility for programs can be based on a person's insurance, income and needs. We appreciate you providing as much information as possible to assure your client/patient is connected to the most appropriate resources.

Does the person have Medicare? *

Original Medicare

Medicare Advantage Plan

No

Unknown

Does the person have Medicaid? *

Full Medicaid

Partial Medicaid

No

Unknown

Is the person a veteran? *

Yes	No
Uknown

Is the person a spouse of a veteran? *

Yes

No

How much is their monthly income? *

Can the person pay for the needed assistance? *

Yes

Possibly

No

Not Sure

How often does the person drive? *

Daily

Occasionally

None

Unknown

(Please note eligibility for some programs are based on a person's driving status, meaning services may not be available if the person is not homebound and still drives.)

If not driving, who provides transportation (check all that apply)? *

How many people reside in the household? *

Additional household members: *

Spouse

Adult Child(ren)

Relative

Other Other

Does the person need assistance with any of the following? *

I would like information on the following Senior Services program(s): *

I would like the following referral list(s): *

I would like the information: *

Emailed to me

Emailed to client/patient

Mailed to client/patient (with "Directory of Services" booklet)

Mailed to client/patient (without "Directory of Services" booklet)

Referrals to Programs (Permission to Share Information)

Senior Services' Help Line can connect your client/patient to the community partners listed below. Help Line will have the selected provider(s) follow up with your client/patient. Please note, once Help Line sends the referral(s) to the selected providers, Help Line will assure it’s receipt but the community partners will contact your client/ patient in accordance to their intake process.

Have you received permission from the client/patient to make these referrals? *

Yes

Who should be the point of contact? (If other than client, please provide name and phone number) *

Please check which provider(s) your client/patient would like to be connected with, making sure your client/patient meets the basic eligibility as noted:

Meals-on-Wheels (MOW):

My client/patient is age 60+, is homebound (not driving or very limited driving) and has trouble preparing or obtaining food. Availability of meals is dependent upon a person’s address and current routes. Evening or weekend meal delivery is not offered.

Senior Lunch (SL)

My client/patient is age 60+, is not homebound and would benefit from the socialization and nutrition offered at one of the Senior Lunch program sites on Mondays, Wednesdays and Fridays. (Persons cannot attend Senior Lunch and participate in Meals on Wheels.)

Special Assistance In-Home (SA In-home)*

My client/patient has full Medicaid benefits, is age 18+ with a disability, meets eligibility for adult care home/ assisted living level of care and would like to apply for this additional monthly income to support their needs and help them remain at home. This program is through our local Department of Social Services.

*Help Line can no longer make referrals to SA In-Home on your behalf. Please contact the Forsyth County Department of Social Services directly at 336-703-3501 for further assistance.

Department of Social Services In-home Aide Program (DSS-IHA)

My client/patient is age 18+, is disabled, needs assistance with housework and does not have an abled bodied individual in the home for this support. My client/ patient may lack the ability to pay for the needed support and would like to be added to the wait list for this grant funded program. (Persons with the ability to hire help will have access to assistance quicker by not utilizing this grant funded program.)

Senior Services' Home Care (SSHC)

My client/patient is age 60+, is homebound (not driving at all) and requires assistance with bathing. My client/patient may lack the ability to pay for the needed support and would like to be added to the wait list for this grant funded program. (Persons with the ability to hire help may have access to assistance quicker by not utilizing this grant funded program. Persons eligible for VA services, active on Hospice or with full Medicaid will need to utilize those benefits.)

Living at Home (LAH)- also known as the CAP-DA waiver

My client/patient has Medicaid (or may qualify or meet the deductible), is age 18+ with a disability, at risk of nursing home placement and would like to go on the waiting list for CAP.

Williams Adult Day Center (WADC)

My client/patient would benefit from the socialization and supervision offered by WADC. Many of the participants enrolled have memory loss. My client/patient is interested in more information on this center and would like to possibly schedule a trial day. There are various funding options for this program.

Family Caregiver Support Program (FCSP)

My client/patient is age 60+ and their caregiver has a short term need for in-home or in-facility respite care. (Persons with the ability to hire help may have access to assistance quicker by not utilizing this grant funded program. Persons who are caring for someone with dementia should be referred to Project Care at 828-485-4267.)

My client/patient is age 55+ raising their minor grandchild (or grandchild with a disability) and would like a referral to our “Grandparents Raising Grandchildren” support group.

Memory Connections

My client/patient has dementia and would (along with their caregiver) benefit from care consultation, a caregiver support group, or other education and support like art classes or an in-home expert consultation by an occupational therapist to manage the challenging behaviors sometimes exhibited by loved ones living with dementia Please specify in the notes section below what service(s) you specifically think your patient and/ or their caregiver would benefit from.

Creative Connections

My client/patient is age 60+ and would benefit from the fulfillment and connection that comes from attending Senior Services’ no-cost Creative Connections art classes available at the Intergenerational Center for Arts and Wellness.

Call Connections*

My client/patient is age 60+, is homebound and would benefit from additional socialization through regular calls from a volunteer.

*Call Connections is not accepting any new referrals at this time.

I am not interested in being connected to any of the above programs at this time

I have a different need and would like to see if Help Line has any resources. Please note your need/question in the notes box below.

Additional Notes

Is there anything else you want to share related to this online request? *

Please click submit below to complete your form.

You will see a success page and also receive a confirmation email (at the address provided above) once we have received your form. Our Help Line team will respond to your inquiry as soon as possible. Please note, if you do not see the success page or do not receive the confirmation email, please email Help Line at helpline@seniorservicesinc.org.

Married	Widowed
Divorced	Single
Separated	Unknown

Spouse	Son
Daughter	Other Family
Neighbor	Friend
Volunteer transportation provider	Trans-Aid
City Bus	Insurance
Other Other

Ambulation	Eating	Med Use	Toileting
Housework	Transportation	Bathing	Phone
Money Mgt	Transferring	Meal Prep	Dressing
Shopping	None of the above	Unknown

Caregiver Resources and Support Services	Dental Assistance
Financial Assistance	In-Home Assistance
Long Term Care Facilities	Senior Housing: Independent Living Options
Home Maintenance/Ramps	Medicare & Medicaid
Consumer Protection & Legal Assistance	Recreation & Self Enrichment
Transportation

About our Services	Creative Connections
Help Line	Home Care
Living at Home/CAP	Meals on Wheels
Senior Lunch	Williams Adult Day Center