Area Agency on Aging of Central Texas - Company Message
AAACT CLIENT INTAKE AND
SERVICE REQUEST ONLINE FORM
(Bell, Coryell, Hamilton, Lampasas, Milam, Mills & San Saba counties only)
 
The information on this form is required by your local service provider, the Area Agency on Aging of Central Texas and the Texas Department of Aging and Disability Services. All information provided will be kept confidential and guarded against unofficial use. Information gathered through an intake or through an assessment may be shared to effectively plan, arrange and deliver services
to meet individual client needs.
 
AAACT staff is not authorized to contact the client unless a Release of Information is on file with the referring agency. All others, AAACT staff will call the contact person first.
 
 
Submit A Referral
Contact Person
Relationship to Client
Contact Phone #
Professionals: Release of Information on file & explained to client?
Professionals: Agency Name
Client's Full Name
Client's Street Address/Apt #
Client's City
Client's Zip Code
Client's County
Client's Date of Birth
Client's Phone #
Gender
Marital status
Veteran Status: Is the client...
Ethnicity
Race
How many in household including client?
Monthly Income
Estimated Resources (Not including Home/Vehicle)
Is client enrolled in:
Medicare
Medicaid
Medicare Number
Medicaid Number
Emergency Contact: Name/Relation/Phone
Primary Doctor/Location/Phone
Services currently in the home
Home Health
Hospice
State In home attendant
VA in home attendant
Home Delivered Meals
Emergency Response Services
Private pay attendant
Does client have a caregiver?
Yes
No
If yes, caregiver name/relation/phone
Diagnosis/Medical Problems
Services needed or identified
Additional Comments
 
Area Agency on Aging of Central Texas
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2180 N. Main, P.O. Box 729
Belton , TX , 76513 USA
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Phone 2547702330
Fax 2547702349
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