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 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

Please check what you are seeking Help Line's assistance with: *
Client/patient lives in Forsyth County. (If not, please contact that county's Senior Services.*

Professional Contact Information

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

Client/Patient Information

Please fill this information out about the client/patient you are serving.
Please check: *
Marital Status: *

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? *
Does the person have Medicaid? *
Is the person a veteran? *
Is the person a spouse of a veteran? *
Can the person pay for the needed assistance? *
How often does the person drive? *
(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)? *
Additional household members: *
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: *

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? *
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):
Senior Lunch (SL)

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)
Senior Services' Home Care (SSHC)
Living at Home (LAH)- also known as the CAP-DA waiver
Williams Adult Day Center (WADC)
Family Caregiver Support Program (FCSP)
Memory Connections
Creative Connections
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

Additional Notes

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
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