Make a Referral | Direction Home Akron Canton

Secure Referral to the Aging and Disability Resource Center

This form is designed for use by staff in hospitals, nursing homes or other organizations to refer individuals to Direction Home Area Agency on Aging & Disabilities Aging and Disability Resource Center (ADRC). Referrals can also be made to the ADRC by calling 1-877-770-5558. IMPORTANT: For emergencies, call 911. For Adult Protective Services (APS) referrals, call 1-844-640-8292. To expedite your referral, please complete as many fields as possible.

Referral Source

Agency Name

Name

Phone

Patient Information

Patient Name

Phone

Home Address

City, State & Zip

Current Location

Please describe location

DOB

Last 4 digits of SSN

Does the patient have a guardian?

Name

Phone

Does the patient have a DPOA?

Name

Phone

Who should we contact regarding this referral?

Name

Phone

Physician Information

Physician Name

Physician Phone

Physician Unknown

Questions

Has there been a recent decline in health?

Please explain

Have they been to the emergency room in the last 60 days?

Please explain

Is the caregiver showing signs of stress?

Please explain

Is their housing currently unsafe?

Please explain

Have they had a recent medical procedure?

Please explain