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Serving Langlade, Lincoln, Marathon, and Wood counties
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Professional Referral Form

Please complete this form to make a professional referral to the ADRC-CW for a mutual customer. Professionals making a customer referral to the ADRC-CW meal program should confirm: The customer lives in Langlade, Lincoln, Marathon, or Wood County Wisconsin and meets the basic eligibility requirements for the program: 1) Age 60 or older, and 2) Confined to their home because of an illness or disability, and 3) Unable to prepare their own meals. Delivery is dependent on route availability.

  • Name and phone number to contact if not the customer.
  • Please choose one
  • Name of the person making the professional referral and the agency.
  • Email of the person making the professional referral.
  • What is the main reason for referring the customer to the ADRC-CW?
  • Briefly describe the need for the referral.
  • Select one
  • Please upload supporting documentation. (Health and physical, current diagnosis, guardianship/POA)
    Drop files here or
    Accepted file types: pdf, Max. file size: 256 MB.