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Social Work Assistance Intake Form- Personal Assessment

2. Social Work Assistance
   Personal Assessment
4. 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, 910-410-1134 or 910-997-4491 or complete the form below and our Social Worker will contact you.
6. Date*
   Date
7. Name*
9. Date of Birth*
   Date of Birth
   Enter month day and four digit year ( xx/xx/xxxx)
10. Last four digits of Social Security Number*
11. Phone Number*
12. Additional Phone Number
14. E-mail
16. Address 1*
18. Address 2
20. City*
21. State*
22. Zip Code*
24. Directions to Home
    (Optional)
26. What type of assistance are you seeking?*
28. What type of income do you receive?*
30. Do you receive Medicaid?*

    1. Yes
    2. No
    3. I'm not sure
31. If Yes, what is your Medicaid Number?*
32. If no or unsure, would you like to apply?

    1. Yes
    2. No, not at this time

    If you check yes, Aging Services' Social Worker will contact you.
34. Primary Care Doctor*
35. What type of Medical Insurance do you have?*
37. Do you receive Food and Nutrition Services?*

    1. Yes
    2. No
    3. I'm not sure
38. If Yes, how much do you receive monthly?*
39. If no or unsure, would you like to apply?

    1. Yes
    2. No

    If you check yes, Aging Services' Social Worker will contact you.
41. Do you need help with Transportation?*

    1. Yes
    2. No
43. Who provides your Electricity?*

    1. Duke Energy
    2. Pee Dee Electric
    3. I am not sure
44. What is your Account Number?*
46. Does anyone live with you?*

    1. Yes
    2. No
47. If Yes, who?*
49. Do you receive any services or attend any programs offered by Richmond County Aging Services?*

    1. Yes
    2. No
    3. I'm not sure
50. If yes, what services or programs do you participate in?
52. Have you been diagnosed with Dementia or Alzheimer's? *

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

    1. Yes
    2. No
    3. I am not sure
56. How can we best help you?
58. Is there anything else we should know?
60. 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. *

    1. Yes
    2. No, please do not contact me at this time
62. Form updated: 10/21/2019
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64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit Submit and Print

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