Make a Referral

Council on Aging offers a variety of programs and services that help eligible older adults and people with disabilities live safely and independently in their homes and communities. These services may include: home-delivered meals, personal care, care management, transportation, an emergency response device, skilled nursing, and more.

If you are a professional (healthcare, first responder, social worker, COA provider, etc.) who works with someone who may benefit from these services, please complete the secure referral form below. Please provide as much information as possible – some information is required.

Staff in our Aging and Disability Resource Center will respond directly to the person the referral is made for (or another contact you designate on the form) within 1-2 business days. Please indicate on the form below if you would like to receive an update regarding this referral.

If you have problems using this form, please call (513) 721-1025 and select Option 1.

If you need information about our programs and services or have another type of request, please use our Contact Us form.

Person in need of services:

Yes No I Don't Know

Where is this person currently located?

  • Own Home
  • Caregiver's Home
  • Hospital
  • Skilled or Long-term Care Facility
  • Other

Person making referral:

        Yes         No       

* Whom should we contact about this referral?

  • Person in need of services (as entered above)
  • Person making referral
  • Other (such as a caregiver or guardian)

Based on your knowledge of this individual, what type of assistance does he/she need?

Please review the list of activities. Which activity(ies) does this individual need assistance with? Check all boxes that might apply. Check the box even if you are not sure. Use the text box below to provide additional information or comments that may help us determine what services this individual may need.

  • Bathing
  • Dressing
  • Grooming (nails, teeth, hair, etc.)
  • Toileting
  • Transfers (getting out of a bed or chair, in and out of shower)
  • Mobility (ability to walk, get out of bed)
  • Eating
  • Taking Medication (remembering when and how to take medication)
  • Using the Telephone
  • Legal/Financial (help with paperwork or paying bills)
  • Cleaning
  • Meal Preparation
  • Shopping
  • Laundry
  • Transportation


Enter the words above.

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175 Tri County Parkway | Cincinnati, OH 45246 | (513) 721-1025