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. For any non-emergency questions that require immediate attention, please call the ADRC directly to speak with an Aging and Disability Resource Center Screener Monday-Friday between 8am-5pm.

IMPORTANT: For emergencies, call 911. Call 911, visit the Emergency Department or local hospital, and/or reach out to your doctor for any urgent issues about pressing medical conditions. For Adult Protective Services (APS) referrals, call 1-844-640-8292. To expedite your referral, please complete as many fields as possible. If you have issues regarding your care in a nursing home, assisted living, or home-based setting please call our office and ask to be connected with the Ombudsman department.

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

Current Concerns

CAPTCHA

An Aging and Disability Resource Center Screener will respond to the web request within 24 hours via email or phone to the contact person you requested. Professional referral sources working with Direction Home Aging and Disabilities to coordinate care will receive follow up information via email or phone following a successful or unsuccessful contact with the community member.

Direction Home’s Aging and Disability Resource Center offers tailored, unbiased and reliable information that provides choices for people to live independently in the place they want to call home for all levels of income and physical need. Our representatives strive to raise awareness on the long-term care options and provide objective information to empower community members and their care team professionals to make informed decisions about the next steps in the process.