Do you know someone, possibly yourself, who could benefit from the services SARCOA has to offer? Help starts here. Please fill out the form below and click the SEND button. We will review your submission and get in touch as soon as possible. We want to help!

Referral Form

Info for the person needing assistance

    This referred individual has been made aware of this referral: YesNo

    Ailments (Check All That Apply)
    AIDS/HIVAlcohol/DrugsAlzheimer'sAmputationArthritis, OsteoArthritis, RheumatoidAsthmaCancerCHFCOPDCVADementiaDiabetesEDEMAHeart DiseaseHypertensionMental IllnessMental RetardationOsteoporosisParalysisParkinson'sRenal FailureSeizureBlindnessCataractsGlaucoma

    Are you filling out this referral form for yourself? YesNo

    Income

    What outcome would you like from this referral?
    Help With: (Check All That Apply - Required)
    AESAP/SNAPAlabama CaresCaregiver ServicesEnergy AssistanceFood AssistanceHomemaker ServicesHome HealthLegal AssistanceMedicaid WaverPersonal CareSenior CenterSHIP CounselingHomebound MealsPrescription AssistanceOther

    Caregiver Information

    As an area agency on aging, SARCOA works to bring together funding sources and service providers to deliver services that assist both senior citizens and individuals with disabilities, helping them maintain their dignity, independence and quality of life.

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