978-750-4540

DO NOT USE THIS FORM TO FILE A PROTECTIVE SERVICES REPORT.  Please call the Elder Abuse Hotline at 1-800-922-2275 to report cases of abuse.

Please use this referral form for applicants residing in Danvers, Marblehead, Middleton, Peabody and Salem.

 

Referral Form

  • 1. Referral Source

    If you are asking for services for yourself please skip to Section 2.
  • 2. Applicant Information

  • Eligibility for the Home Care Program is based on age. An individual must be 60 years of age or older. If under 60, must be diagnosed with a dementia related disease, medical documentation is required.
  • 3. Insurance Information

  • 4. Income

  • No income limits, but there is a copayment based on income using a sliding fee scale.
  • 5. Emergency Contacts

  • 6. Reason for Referral

    Please indicate below what tasks you or the applicant needs help with? Check all that apply.
    To be eligible for services an individual must require assistance with a number of activities of daily living,for example, meal prep, housework, laundry, shopping, personal care, showering, and dressing.
    Our Caregiver Support team provides resources, education, guidance, training and empowerment to those caring for older adults and people with disabilities. These services are at no cost to the caregiver.
  • 7. Primary Care Doctor

  • 8. Recent Hospitalization or Rehab Stay

  • This field is for validation purposes and should be left unchanged.