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2. Applicant must be at least 60 years of age or older to apply for In Home Aide Level I or Home Delivered Meals services.
4. Application for Services*

   Please check what service(s) you are applying for.

   1. In Home Aide
   2. Home Delivered Meals

   1. Adult Social Services Assistance
5. Please Note:
   There are waiting lists for both In Home Aide Level I and Home Delivered Meals services.
7. Date of Application*
   Date of Application
9. First Name*
10. Middle Name
11. Last Name*
13. Date of Birth*
14. Last 4 Digits of your Social Security Number*
15. Phone Number*
16. Additional Phone Number
18. Email Address
20. Would you like to be added to our Email Distribution List?

    By doing so, you will receive occasional monthly e-mails providing you with our Agency's Newsletter and/ or other valuable information related to what's going on in Richmond County for older adults.

    1. Yes
    2. No
22. Address1*
24. Address2
26. City*
27. State*
28. Zip*
30. Please provide directions to your home.
    We may be able to make a house visit if you or the applicant is home bound or unable to come into the office.
34. Activities of Daily Living (ADL)
    Is the applicant able to do the following ADL's without the help of another Agency or someone else?
36. Bathe Self*

    1. Yes
    2. No
37. Use the Toilet*

    1. Yes
    2. No
38. Walk without help*

    1. Yes
    2. No
39. Are you able to Drive?*

    1. Yes
    2. No
41. Feed Self*

    1. Yes
    2. No
42. Get Dressed*

    1. Yes
    2. No
43. Transfer into and out of a bed or chair*

    1. Yes
    2. No
45. Health Problems

    Please check all that apply. If you need additional space to provide more information, please use the Additional Comments section below.

    1. Alzheimer's Disease
    2. Arthritis
    3. Asthma
    4. Breathing- other
    5. Cancer
    6. Congestive Heart Failure

    1. COPD
    2. Dementia
    3. Depression
    4. Diabetes
    5. Emphysema
    6. Fibromyalgia

    1. Gout
    2. Headaches
    3. Heart Problems
    4. Hypertension
    5. Impaired Hearing
    6. Impaired Vision

    1. Mental Illness
    2. Pain
    3. Recent Fall/ Injury/ Surgery
    4. Stroke
    5. Terminal Illness
    6. Other
47. If other, please specify here.
51. Would you like to be contacted by our Social Worker?*

    A variety of social services are available to meet the needs of those requesting services or information. Among the services that are offered are case management, information and referral, and home visit assessments. Through our many services, groups and activities, we strive to be the all-inclusive conduit for the senior adults in our community. Our Social Worker is also available to make home visits upon request. To make an appointment to see a social worker, contact Richmond County Aging Services at 910-997-8439 or 910-997-4491 or check yes below and our Social Worker will contact you.

    1. Yes
    2. No
    3. I am already in contact with a Social Worker
53. Who is the Agency and/ or Social Worker assisting you?
57. What type of assistance are you seeking?*
59. What type of income do you receive?*
61. Do you receive Medicaid?*

    1. Yes
    2. No
    3. I am not sure
62. If Yes, what is your Medicaid Number?*
64. Who is your Primary Care Doctor?*
66. What type of Medical Insurance do you have?*
68. Do you receive Food and Nutrition Services?*

    1. Yes
    2. No
    3. I am not sure
69. If Yes, how much do you receive?*
71. Do you need help with Transportation?*

    1. Yes
    2. No
    3. I am not sure
73. Who provides your Electricity?*

    1. Duke Energy
    2. Pee Dee Electric
    3. I am not sure
74. What is your account number?
76. Does anyone live with you?*

    1. Yes
    2. No
77. If Yes, who?*
79. Additional Questions
81. Are you a Veteran?*

    1. Yes
    2. No
83. Have you been diagonsed with Dementia or Alzheimer's?*

    1. Yes
    2. No
    3. I am not sure
85. Do you currently have a Smoke Alarm in your home?*

    1. Yes
    2. No
87. Are you currently in need of a Wheelchair Ramp?*

    1. Yes
    2. No
    3. I am not sure
89. Do you receive any of the services provided by Richmond County Aging Services?*

    1. Yes
    2. No
    3. I am not sure
90. If yes, then which?*

    1. In Home Aide Level I
    2. Congregate Nutrition Meal Site
    3. Home Delivered Meals
    4. Other
91. If other, please describe.*
93. Is there anything else we should know or do you have any additional Comments?*
97. Referred By*

    Please check if you are referring yourself or a friend.

    1. Referring myself

    1. Referring someone else
99. Please list your relationship to the applicant.*

    1. Son
    2. Daughter
    3. Physicians Office
    4. Social Worker
    5. Other
100. If other, please specify here.
102. If referring someone else, Is applicant aware of your referral?

     1. Yes
     2. No
104. First Name*
105. Last Name*
107. Address1*
109. Address2
111. City*
112. State*
113. Zip*
115. Phone Number*
116. Additional Phone Number
118. Contact Instructions*

     1. Call Applicant Listed

     1. Call Contact who is making the referral
120. Is there anything else we should know when contacting you?
122. Form Updated 10-21-19
Leave This Blank:


124. 1. Receive an email copy of this form.
125. Email address

     This field is not part of the form submission.

126. Submit Submit and Print

* indicates a required field