Program Referral Form

Complete the referral form below for programs funded by the Kent County Senior Millage (KCSM) and Older Americans Act (OAA).  

Program Referral Form

Please complete the following form for Kent County Senior Millage (KCSM) and Older Americans Act (OAA) programs.

What program(s) are you applying for?(Required)
MM slash DD slash YYYY
Client Address(Required)
MM slash DD slash YYYY
Gender
Live Alone?

How many falls have you had in the past year?
How many times have you been admitted to the hospital in the past year?
How many medications do you take daily?
Do you have family and/or friends involved in your care?
Is it necessary for you to use any durable medical equipment? i.e. cane, walker, oxygen, etc.
Do you receive other services? Such as homemaking/personal care, skilled nursing, home delivered meals, etc.
Do you have any limitations? i.e. arthritis, blindness, etc.
Please select the medical conditions you currently take meds for:
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Contact Us

Grand Rapids Office

500 Cherry St. SE
Grand Rapids, MI 49503

(616) 454-8305

Fax: (616) 454-0461

Holland Office

348 S. Waverly Rd.

Suite 106
Holland, MI 49423
(616) 401-9140

 

Office Hours: Mon-Fri 8-4
On-call: 24/7

eldershelpers@eldershelpers.com

Program Referral Form
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