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:

* First Name

* Last Name

* Phone Number

* Date of Birth

* Does the individual receive Medicaid?

Yes

I Don't Know

Home Address

City

State

Zip

* County

* If this person is receiving care at home from a family member or another unpaid person, would this caregiver be interested in our Caregiver Support Program? About the program

Yes

Where is this person currently located?

Own Home

Caregiver's Home

Hospital (currently, or discharged in last 7 days)

Skilled or Long-term Care Facility (currently, or discharged in last 7 days)

Other

Person making referral:

* First Name

* Last Name

Title

* Organization Name

* Phone Number

* Email

* Type of Referrer

* Do you want to receive an update regarding this referral?

Yes

* 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)

Diagnoses

Additional Comments

Submit

* required information

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