ADRC Referral Form

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859-303-4040
[email protected]
343 Waller Ave, STE 305, Lexington, Kentucky

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Bluegrass Aging and Disability Resource Center Professional Referral Form

ADRC Referral

First and Last Name of Client Date of Birth

MM slash DD slash YYYY
Age Gender Primary Phone NumberName of Contact (If not client) Alternate Phone NumberRelationship to Client

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Is the Client a Veteran?

Yes

No

Client current living arrangement

Lives with spouse

Lives alone

With child/children

Lives with parents

Other – please specify

Specify living arrangments

is the client homebound?

Yes

no

How many people are in the clients household?

1

2

3

4 or more

What services / programs are you referring the client for more information about?

Medicaid

Medicare

Home Delivered Meals

Personal Care

Respite Care

Medicaid Waiver

Homemaker Services

Transportation

Caregiver Support

Assistive Technology – DME, etc

Senior Center Services

Other – please specify

Specify services/programs referred Name of person making referral Agency or Organization Name Primary Telephone NumberBest time to call, if needed Email Address

Does the client know a referral is being made on his/her behalf?

Yes

No

If you have any questions related to this referral, please call the Aging and Disability
Resource Center at 1-866-665-7921 or 859-266-1116 or email [email protected]

About Us
Services
Clients
Careers
Staff
FAQ/Testimonials
Contact