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Social Work Assistance Intake Form- Personal Assessment

  1. Social Work Assistance

    Personal Assessment

  2. 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 complete the form below and our Social Worker will contact you.

  3. Enter month day and four digit year ( xx/xx/xxxx)

  4. (Optional)

  5. Please indicate how many live in your home.

  6. Do you receive Medicaid?*

  7. If no or unsure, would you like to apply?

    If you check yes, Aging Services' Social Worker will contact you.

  8. Do you receive Food Stamps?*

  9. If no or unsure, would you like to apply?

    If you check yes, Aging Services' Social Worker will contact you.

  10. Do you need help with Transportation?*

  11. Do you receive any services or attend any programs offered by Richmond County Aging Services?*

  12. By submitting this Social Work Assistance Form, I am authorizing Richmond County Aging Services' Social Worker to contact me at the information I provided above. *

  13. Form updated: 03/21/2018

  14. Leave This Blank:

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