ADRC Professional Referral Form

ADRC Professional Referral Form

The Aging & Disability Resource Center of Winnebago County (ADRC) provides information and assistance for resources, education, connection to publicly funded programs, and support regarding benefits. Programs the ADRC offers are voluntary and provide choices to the customer and/or legal decision maker. When the referral is sent, an ADRC staff member will make two attempts to reach the customer before closing the referral. Customers are welcome to call us directly at 877-886-2372. To assist us with providing the most efficient service, please complete this form with as much information as possible. Fields with an asterisk (*) are required.

Is this individual a resident of Winnebago County, Wisconsin?
Customer or legal decision maker has agreed to referral:

Demographics

Marital Status

If not the customer, who should we contact?

Decision Making Status

If represented, by whom?

Gender
Race
Ethnicity
Interpreter Needed
Current Health Insurance

If NOT RECEIVING MEDICAID, are individual assets under $2,000? (Assets are any funds that can be accessed at any time like checking and savings accounts, money market, 401K, IRA, second property, etc.)

What type of referral are you making? (Select all that apply)

If there is a concern of abuse or neglect of a vulnerable adult, please call our office (877-886-2372) to talk to our Adult Protective Services Department or, if appropriate, contact law enforcement to support with concerns.

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