If you need assistance or want to refer someone please fill out OUR Referral form

If you are unable to complete the I&A Inquiry online, there is a downloadable version available. Please note, you only need to submit one I&A Inquiry per participant.

Client Name(Required)
MM slash DD slash YYYY
Client Address
Caregiver or other person who acts on behalf of client.
Eligibility(Required)
Region- 1A is Detroit, Harper Woods, Highland Park, Hamtramack and the five Grosse Pointes)
Requires assistance with ADLs and IADLs(Required)
Two or more of the following should have checks
Inadequate support systems(Required)
Gross income below $2,523/monthly (Subject to Change)(Required)
Less than $2,000 (single) or $3000 (couple) in liquid assets (e.g., checking, savings)
Medicaid Eligible(Required)
Nutrition: - Home delivered meal services
Transportation: Non- Emergency Medical Transportation
Healthy Aging Services
Electronic Signature(Required)
Representative name or name of person who has completed this form.
MM slash DD slash YYYY