Referrals
Elder Options Intake Pre-Screening Form
This form must be fully completed. This form cannot be processed if consent from the client (or their legal representative) is not provided below.
If you would like to be contacted via SMS, please provide a mobile number in the field below.
*Disclaimer* By providing your mobile number and opting to receive SMS messages from Elder Options, you acknowledge and consent to receive informational and promotional text messages from us. These messages may include but are not limited to alerts, updates, and offers. Message frequency may vary, and standard message and data rates may apply. Consent is not a condition of purchasing goods or services. You may opt-out of receiving SMS messages at any time by replying “STOP” to the received message. Please note that opting out may prevent you from receiving important updates or offers. For help or information, contact our Helpline directly at 1-800-262-2243. We respect your privacy. Your information will be handled in accordance with our Privacy Policy. For more details, please refer to our Privacy Policy on our website.