AgingIS - Self-Referral

Provide Basic Information About the Person Seeking Care

Last Name:*

First Name:*

Date of Birth:

Email:

Home Phone:

Cell Phone:

House Number:

Street:

Apt/Suite:

City:

State:

Zip Code:

County:

Request Type:

Preferred Contact Type:*

Requested By:

Description of Need:

Functional Needs Referral Information

Why does this person needs to be in the FNR?

Homebound/Service Auto Enrollment

Service:

What is their disability?

Vision

Hearing

Mobility

Power Chair?

Yes

Walker?

Yes

Heart Disease

Diabetes

Seizures

Oxygen

Oxygen Machine?

Yes

Mental Health

Controlled by Meds?

Yes

Other

Describe:

Animals in the Home?

Yes

Service Animal?

Yes

Type:

Is English a second language?

Yes

Primary Language:

Notes:

Submit

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

We are committed to protecting and respecting your privacy. This Privacy Policy and the Conditions of Use sets out the basis on which any personal data we collect from you, or that you provide to us, will be processed by us. Please read the following carefully to understand our views and practices regarding your personal data and how we will treat it.

For the purpose of European Union Data Protection legislation, We (as defined and detailed in this website (our Site)) are the data controller.

Information we may collect from you

We may collect and process the following data about you:

	•	Information that you provide by filling in forms on our Site. This includes information provided at the time of registering to use our Site, subscribing to our service, posting material or requesting further services. We may also ask you for information when you enter a competition or promotion sponsored by us, and when you report a problem with our Site.

	•	If you contact us, we may keep a record of that correspondence.

	•	We may also ask you to complete surveys that we use for research purposes, although you do not have to respond to them.

	•	Details of transactions you carry out through our Site and of the fulfilment of your orders.

	•	Details of your visits to our Site including, but not limited to, traffic data, location data, weblogs and other communication data, whether this is required for our own billing purposes or otherwise and the resources that you access.

IP Addresses

We may collect information about your computer, including where available your IP address, operating system and browser type, for system administration and to report aggregate information to our advertisers. This is statistical data about our users' browsing actions and patterns, and does not identify any individual.

Cookies - When someone visits this website we collect standard internet log information and details of visitor behaviour patterns. We do this to find out things such as the number of visitors to the various parts of the site. We collect this information in a way which does not identify anyone. We do not make any attempt to find out the identities of those visiting our website. We will not associate any data gathered from this site with any personally identifying information from any source.

Privacy Policy