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: _______________________
REFERRAL and ACTION PLAN
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: dhill@aaapbtc.org.
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
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Area of Assistance |
Explanation of Need |
Help Requested/ Approximate Cost |
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Food Assistance
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Housing Assistance
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Prescription/Medical Assistance
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Other
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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)
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Date of FIRST contact with client: _____________________
Summary of Issues
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
ACTION PLAN
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What needs are identified?
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Applicant action items |
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Where referrals made to other agencies for assistance? Note where.
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Notes: |
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: dhill@aaapbtc.org
Date and Outcome of request? (Circle one) Date: ____________________ Approved Denied
Outcome:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
