Search for:
Home
Volunteer
Donate
Make a Donation
2019 Sponsors
HIPAA
Privacy Policy
Contact
Menu
About Us
Who We Are
History
Advocacy
Advocacy Tips
Contact Your Federal Legislator
Contact Your State Legislator
Medicaid Caps & Cuts
Board Information
Archived Information
Executive Team
Reports
Work With Us
Current Providers
Employment
Request for Proposals
Resources
FAQ
Links
Consumers Affordable Resource for Energy (CARE)
Caregiver Resources
Senior Centers
Senior Resource Directories
Programs & Services
Information & Assistance
Services List
Health Access Information
MI Choice Waiver Program
Medicare/Medicaid Assistance (MMAP)
Independent Living Programs
Health & Wellness Programs
Caregiver & Volunteer Programs
Upcoming Events
Calendar
Annual Meeting
Senior Power Day
Big Wheels Deliver Meals
Older Michiganians Day
News & Press
Community Outreach
Press Releases
Newsletters
City of Flint’s Water Issue
Fraud, Waste, & Abuse
Report Suspicions
About Us
Who We Are
History
Advocacy
Advocacy Tips
Contact Your Federal Legislator
Contact Your State Legislator
Medicaid Caps & Cuts
Board Information
Archived Information
Executive Team
Reports
Work With Us
Current Providers
Employment
Request for Proposals
Resources
FAQ
Links
Consumers Affordable Resource for Energy (CARE)
Caregiver Resources
Senior Centers
Senior Resource Directories
Programs & Services
Information & Assistance
Services List
Health Access Information
MI Choice Waiver Program
Medicare/Medicaid Assistance (MMAP)
Independent Living Programs
Health & Wellness Programs
Caregiver & Volunteer Programs
Upcoming Events
Calendar
Annual Meeting
Senior Power Day
Big Wheels Deliver Meals
Older Michiganians Day
News & Press
Community Outreach
Press Releases
Newsletters
City of Flint’s Water Issue
Fraud, Waste, & Abuse
Report Suspicions
About Us
Who We Are
History
Advocacy
Advocacy Tips
Contact Your Federal Legislator
Contact Your State Legislator
Medicaid Caps & Cuts
Board Information
Archived Information
Executive Team
Reports
Work With Us
Current Providers
Employment
Request for Proposals
Resources
FAQ
Links
Consumers Affordable Resource for Energy (CARE)
Caregiver Resources
Senior Centers
Senior Resource Directories
Programs & Services
Information & Assistance
Services List
Health Access Information
MI Choice Waiver Program
Medicare/Medicaid Assistance (MMAP)
Independent Living Programs
Health & Wellness Programs
Caregiver & Volunteer Programs
Upcoming Events
Calendar
Annual Meeting
Senior Power Day
Big Wheels Deliver Meals
Older Michiganians Day
News & Press
Community Outreach
Press Releases
Newsletters
City of Flint’s Water Issue
Fraud, Waste, & Abuse
Report Suspicions
Service Request
Full Name
*
Email
Phone
*
Address
*
Address Line 1
Address Line 2
City
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
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 release date
Fan attached?
Yes
No
Please upload FACE sheet if available
Requested Services
Home Help
Respite
Transportation
Personal Care
Medication Management
Home Delivered Meals
Medical Equipment
Nursing Home Transportation
Home Safety Equipment
Adult Foster Care
Adult Day Center
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 with someone?
Yes
No
If yes, with whom?
Have you experienced Forgetfulness?
Yes
No
Are you able to get out of bed?
Yes
No
Are you able to prepare your own meals?
Yes
No
Are you able to bathe independently?
Yes
No
Are you able to complete personal care tasks independently? (grooming, dressing, toiling, etc.)
Yes
No
If no, please explain.
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.
Who is your primary contact?
Self
Family/ Friend
Legal Guardian
Contact Full Name
Relationship
Email
Phone
Referred by (Name)
*
Agency/Title
Your Email
*
Phone
Other documents to support your request if applicable.
Website
Submit
