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Adult Services Referral

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We care about Wilson County's Older & Disabled Adults. Is there an older or disabled adult who needs services in order to remain home safely? If so, please fill out this form and click submit. A social worker will respond to you within 48 hours.

PLEASE DO NOT MAKE ADULT PROTECTIVE SERVICES REFERRALS ON THIS FORM. CALL 206.4000 OR 911 AFTER 5:00 PM. Thank you!

Older/Disabled Adult Information

Name of Older/Disabled Adult:*

Address:*

City:*

State:

Zip:

Daytime Phone Number:*

Email Address:

Date of Birth*

Last four digits of individual's Social Security Number

Contact name and phone number

Does individual have?*

Medicaid

Food Assistance

In order for our department to make an assessment of needs, please list a brief description:*

Thank you for completing this Adult Service Referral.
PLEASE DO NOT MAKE ADULT PROTECTIVE SERVICES REFERRALS ON THIS FORM. CALL 206.4000 OR 911 AFTER 5:00 PM.
Thank you!

* indicates required fields.

County of Wilson North Carolina Old Fashioned Charm with a Modern Twist

2201 Miller Road South • Wilson, NC 27893 • Ph. (252) 399-2803
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