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ADRC Individual Referral Form

ILRC: (805) 650-5993 | VCAAA: (805) 477-7300

This form is intended to be completed by either a service provider, discharge staff, or the individual themself and is for use to refer individuals to the Ventura County Aging & Disability Resource Center (ADRC). The individual will be offered short-term service coordination and access to the following services through the Independent Living Resource Center: advocacy, benefits counseling, housing assistance, access to assistive technology, private registry of caregivers, and independent living skills training.

Complete this referral form below and click the "Submit ADRC Referral Form" button when finished. Or you may print out this page to fill out by hand and send it to Kelly Kivlahan at ILRC by email kkivlahan@ilrc-trico.org or fax (805) 650-9278. An intake will be scheduled within 1-2 days of receipt. Please allow 5 days advance notice prior to an individual's discharge from a medical facility. Individuals referred must have a point of contact that will participate in the intake process and service coordination if they are unable to do so themselves.

Client Information


Please enter your first name.
Please enter your last name.
Please enter an email address.
Please enter a phone number.
Please enter your address.
Please enter your city.
Enter your state.
Please enter your zip code.

Are you currently homeless?

Are you a U.S. Veteran?

What insurance do you have?

What is your source of income?

What is your race / ethnicity?

What what is your gender?

Support Network


Do you have family members in the area?

Is a guardian, conservator, or person with power of attorney involved?

What is your engagement level in the community?

Housing Information


Choose your current living situation:

What type of housing do you currently have?

If have subsidized housing, what type?

Overall



Do you have a terminal illness?

Do you have cognitive limitations?

Choose your mental status:

Choose your substance abuse concern / suspicion level:

Current Needs



Choose your ambulatory status:

Choose your diet and nutrition status:

Choose your hygiene needs:

Choose your dressing needs:

Choose your overnight / bedtime needs:

Choose your caregiving needs:

Choose expectations for caregiving needs:

Notes