We are VAAA
History
Advocacy
Contact Your Federal Legislator
Contact Your State Legislator
Board Information
Archived Information
Reports
Work With Us
Employment
Request for Proposals
Current Providers
Partnerships
Resources
Information & Assistance
Caregiver Resources
Community Resources
Elder Abuse Information
Health Resources
Senior Centers
Senior Resource Directories
State and National Resources
Programs
Caregiving
Care Management
Case Management
Community Transition Services
Health & Wellness
Home Delivered Meals
MI Choice Waiver Program
Telephonic Wellness Checks
Volunteering
Events
Annual Implementation Plan Public Hearings
Annual Meeting
Big Wheels Deliver Meals
Community News & Press
Older Michiganians Day
Senior Power Day
Fraud, Waste & Abuse
Current Scams
Fraud, Waste & Abuse Education
Report Medicaid Suspicions
Contact Us
Senior Spotlight
We are VAAA
History
Advocacy
Contact Your Federal Legislator
Contact Your State Legislator
Board Information
Archived Information
Reports
Work With Us
Employment
Request for Proposals
Current Providers
Partnerships
Resources
Information & Assistance
Caregiver Resources
Community Resources
Elder Abuse Information
Health Resources
Senior Centers
Senior Resource Directories
State and National Resources
Programs
Caregiving
Care Management
Case Management
Community Transition Services
Health & Wellness
Home Delivered Meals
MI Choice Waiver Program
Telephonic Wellness Checks
Volunteering
Events
Annual Implementation Plan Public Hearings
Annual Meeting
Big Wheels Deliver Meals
Community News & Press
Older Michiganians Day
Senior Power Day
Fraud, Waste & Abuse
Current Scams
Fraud, Waste & Abuse Education
Report Medicaid Suspicions
Contact Us
Senior Spotlight
DONATE NOW
MAKE A REFERRAL
Fill out a service request today!
Please enable JavaScript in your browser to complete this form.
Is the senior informed of this referral?
Yes
No
Is the client able to answer for themselves?
Yes
No
Client Information
Full Name
*
Address
*
Address Line 1
Address Line 2
City
— Select state —
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
*
Race
Gender
Social Security Number
Birthday
Marital Status
Residence (alone, spouse, child, etc)
Gross Monthly Income (estimated)
Assets
Above $2,000
Below $2,000
Do you have
Medicare
Medicaid
Both
Neither
Have you been hospitalized in the last 30 days?
Yes
No
If so, where?
Current Diagnosis
Are you currently in the hospital?
Yes
No
Anticipated discharge date
Requested Services
Home Help
Respite
Transportation
Personal Care
Medication Management
Home Delivered Meals
Medical Equipment
Nursing Home Transition
Home Safety Equipment
Adult Foster Care
Adult Day Center
Preliminary Information
Is there currently someone paid to provide assistance in the home?
Yes
No
If yes, whom?
Do you receive oxygen 24/7?
Yes
No
Do you live alone?
Yes
No
If no, with whom?
Do you have significant memory loss?
Yes
No
Are you able to get out of bed?
Yes
No
Are you able to prepare your own meals?
Yes
No
Do you currently receive Dialysis?
Yes
No
Are you able to complete personal care tasks independently? (grooming, dressing, bating, toiling, etc.)
Yes
No
Do you currently drive?
Yes
No
Do you currently use any of the following assistive devices?
Wheel Chair
Cane
Walker
Lift
Other
Do you have a history of mental illness?
Yes
No
If yes, please explain.
Contact/Referral Information
Contact Full Name
Relationship
Email
Phone
Referred by (Name)
*
Agency/Title
Your Email
*
Phone
Other Comments
Other documents to support your request if applicable.
Click or drag a file to this area to upload.
Would you/contact person like a referral status update?
Yes
No
If yes, please specify the email where the status updated should be directed.
Comment
Submit
Get Started with Senior Services
Get Started with Senior Services
About This Sidebar
You can quickly hide this sidebar by removing widgets from the Hidden Sidebar Settings.
Recent Posts
Annual Implementation Plan Public Hearings
March 12, 2025
2025 Spring Classes
February 3, 2025
Become a 2025 Sponsor
January 8, 2025
Categories
COVID-19
Lifestyle
News
Others
People
Post
Press Releases
Resources
Uncategorized
WordPress
Meta
Log in
Entries feed
Comments feed
WordPress.org
