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Intake and Referral Form: Ohio ADRC
02/04/2008 | Requests *Summary
What questions should be asked when someone first contacts and ADRC? Ohio’s Aging and Disability Resource Network has provided this example of their Intake and Referral Form. Questions address contact information, income, employement, disability, insurance, benefits, and living arrangements. There is also space for referent information.
Author
Available Files
- Form Word (30K, 3 pages)
- Form PDF (64K, 3 pages)
- Website Off-site link
Keywords
Information and Referral; Aging and Disability Resource Center
Topic
Aging Issues, Developmental/Intellectual Disabilities, Resource Center, State/Agency Information
Type/Tool
Assessments, Links / Websites
Source
Grantee produced, Ohio
State
Ohio, All States/Territories
Date Created
02/13/2008
Contact
Aging and Disability Resource Network Ohio Department of Aging
50 W. Broad St., 9th Floor
Columbus, OH 43215
614-466-6191
50 W. Broad St., 9th Floor
Columbus, OH 43215
614-466-6191
Short URL
Permission to use any element of this document should be obtained by the above named contact person. Always name the originator as the source of this material.
* Reflects requests since January 1, 2007
Options
HCBS / Clearinghouse for the Community Living Exchange Collaborative / (http://www.hcbs.org)