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Application for In Home Aide Level I, Home Delivered Meals and/ or Social Services

  1. Applicant must be at least 60 years of age or older to apply for In Home Aide Level I or Home Delivered Meals services.

  2. Application for Services*

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

  3. Please Note:

    There are waiting lists for both In Home Aide Level I and Home Delivered Meals services.

  4. 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.

  5. We may be able to make a house visit if you or the applicant is home bound or unable to come into the office.

  6. Activities of Daily Living (ADL)

    Is the applicant able to do the following ADL's without the help of another Agency or someone else?

  7. Bathe Self*

  8. Use the Toilet*

  9. Walk without help*

  10. Are you able to Drive?*

  11. Feed Self*

  12. Get Dressed*

  13. Transfer into and out of a bed or chair*

  14. Health Problems

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

  15. 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.

  16. Do you receive Medicaid?*

  17. Do you receive Food and Nutrition Services?*

  18. Do you need help with Transportation?*

  19. Who provides your Electricity?*

  20. Does anyone live with you?*

  21. Additional Questions

  22. Are you a Veteran?*

  23. Have you been diagonsed with Dementia or Alzheimer's?*

  24. Do you currently have a Smoke Alarm in your home?*

  25. Are you currently in need of a Wheelchair Ramp?*

  26. Do you receive any of the services provided by Richmond County Aging Services?*

  27. If yes, then which?*

  28. Referred By*

    Please check if you are referring yourself or a friend.

  29. Please list your relationship to the applicant.*

  30. If referring someone else, Is applicant aware of your referral?

  31. Contact Instructions*

  32. Form Updated 10-21-19

  33. Leave This Blank:

  34. This field is not part of the form submission.