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CHOICE Evidence-Based Registration

CHOICE Evidence-Base Registration

"*" indicates required fields

This field is for validation purposes and should be left unchanged.
Have you ever participated in Aging Ahead programming or a program supported by Aging Ahead and completed the required annual assessment?*
Please Note: If you answer “Yes” and Aging Ahead does not have a current annual assessment on file for you, you may not be considered for participation in this class. Class Registration and Selection: Space is limited. Participants are prioritized based on Greatest Social Need and Greatest Economic Need, rather than on a first-come, first-served basis. Notification: You will be notified one week before the class begins if you have been selected to participate or placed on the waitlist.
Name*
Address*
Birthdate (MM/DD/YYYY)*
Please enter a number greater than or equal to 1.
Emergency Contact
Emergency Contact Phone Number

FRAIL

Considered positive if score is greater than or equal to 3
Are you fatigued?*
Can you walk up one flight of stairs?*
Can you walk one block?*
Do you have more than 5 illnesses?*
Have you lost a significant amount of weight in the last 6 months?*

SARCF

Considered a positive if score is greater than or equal to 3
Do you have difficulty lifting and carrying 10 pounds?*
Do you have difficulty walking across a room or transferring from a chair or bed?*
How many times have you fallen in the last year?*
Greatest Economic Need: Is this person’s income at or below 185% of the current Federal Poverty Level? • 1 person: $15,650 Family of 2: $21,150 Family of 3: $26,650 For each additional person, add $5,500.*
Do you have a physical or mental condition that makes it more difficult for you to feel socially connected to others?*
Do you have trouble understanding or communicating because of challenges with spoken or written language?*
Do you feel isolated or face discrimination because of your religious beliefs or affiliation?*
Have you disclosed your HIV status?*
Do you have a chronic health condition that makes it more difficult to stay socially engaged?*
Are you currently experiencing housing instability or at risk of losing your housing?*
Do you have any safety concerns involving others?*
Do you have another condition or status that restricts your ability to perform normal or routine tasks and/or threatens your capacity to live independently?*
Have challenges with technology made it harder for you to stay in touch with family, friends, or others?*
Have you lost a primary caregiver within the past year or since your last assessment?*
Do you live alone?*

Other:

Do you feel your needs are being met?*
Are there any obstacles that restrict you from leaving their home?*
To initiate services, the Area Agency on Aging must share the person's information with contracted service providers, such as The Oasis Institute. Do you give consent?*

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    • CHOICE Evidence-Based Registration
  • Community Options and Services
    • I’m A Caregiver
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  • Meals on Wheels
  • Public Education and Outreach

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Your gift helps us support older adults in St. Louis, St. Charles, Franklin and Jefferson counties so they have opportunities to live with honor and dignity.

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Our mission is we support individuals through the journey of aging. Our vision is for all individuals to have opportunities to age with honor and dignity.

Contact Us: (800) 243-6060 or info@agingahead.org

14535 Manchester Rd, Manchester, MO 63011

EIN: 43-1833987

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