No Wrong Door/Senior Crisis Prevention Application

No Wrong Door/Senior Crisis Prevention Application

Senior Crisis Prevention Application

Program Overview

The Senior Crisis Prevention Program will provide one time crisis intervention for seniors over 60 or a persons with a disability who live in Palm Beach, Martin, St. Lucie, Indian River and Okeechobee Counties.

Program Eligibility

  • The identified request for assistance must be related to the COVID Pandemic or the mitigation of consequences from COVID if the need goes unmet. 
  • Participant must live in the five county area and be a senior or a person with a disability.
  • Participants may request assistance only once time from the fund. 

Program Guidelines

  • No funds will be given directly to the client.  Payment will be arranged with the vendor or contractor directly.
  • Applications for financial assistance will need to be approved by the ADRC committee. Please allow up to 30 Days for review.
  • This funding is payer of last resort, if other funding resources and agencies such as Medicare, EHEAP, Food Stamps, and Extra Help etc. are available they should be approached first.
  • This fund is not for old debt such as past due bills. (i.e. past medical bills, credit card bills etc.)


Documents Required

  • Copy of Valid ID
  • Proof of financial need (proof could be Medicaid, Food Stamps, or bank statements)
  • An official estimate of the cost of any appliances requested or work order for services to be completed, must be included
  • If there is a remaining balance to be paid beyond the $1,500 award, a written statement may be requested confirming the remaining balance will be covered at Client’s expense.

I authorize The Area Agency on Aging to assist me in seeking resolution to the identified needs.


Applicant signature __________________________________                    Date: _______________________                                                                   





Client Name:  ______ ______________________                                           DATE: _____                       

Applicant street address:  _______________________________________________________


City: ____ _____ ____               State_    County____________                 _ Zip code: __


Best Phone: ____________________            Alternate Phone: _________________________________


Email address: ________________________ Date of Birth: __________________________  AGE:    _____


Do you own or rent:  __rent _________  How many people live in the home?  ________


Contact person other than client:  Name ______Phone:


Give a Description of the need:  How does it relate to COVID? _____  ______________________________________________________________________________________________________





Have you sought assistance from other agencies in the last six months?      Yes   or   No

What type of assistance did you receive?  _____________________________________________________________________________________________________________________________________________________________________________________________________________________



Return completed form to Don Hill, Helpline Director:   FAX – 561-214-8670 or Email:

Area Agency on Aging – Palm Beach Treasure Coast.  4400 N. Congress Avenue West Palm Beach, FL 33408



Staff to complete Items Below

Crisis Assistance Needed

Area of Assistance

Explanation of Need

Help Requested/ Approximate Cost

Food Assistance





Housing Assistance





Prescription/Medical Assistance










How well does client perform ADL/IADL

Is client on the state priority waitlist and for what programs?


Yes     NO   Programs

What are other resources/ supports in client’s life? (neighbor/ family)




Date of FIRST contact with client: _____________________

 Summary of Issues




What needs are identified?




Applicant action items


Where referrals made to other agencies for assistance?  Note where.   






  • ADRC – MSP/Extra Help/Food Stamps
  • Food pantry
  • Other_____________



Is there a need for financial assistance from Senior Crisis Prevention fund?

Approximate dollar amount?  _________________

To cover what need? _________________________________________________________________________

Name of a company for purchase goods or services? ________________________________________________

Phone number of company: ____________________________________________________________________

Date Email Request made to ADRC?  _________________________________Email:

Date and Outcome of request? (Circle one)    Date: ____________________ Approved             Denied