One Step Ahead Fall Prevention Program referral form

Thank you for submitting a referral. Your request will be reviewed for eligible enrollment. A program health educator will contact you and the individual referred, if different, within 1 - 3 business days of receipt, to discuss the program and next steps. If submitting a referral on behalf of another person, please talk with the individual about the reason for the referral and discuss the services offered by the One Step Ahead Fall Prevention program.

Today's date

Today's date

1. Enrollment criteria

To enroll, all criteria must be fully met. Please review each criterion. Select all that apply to the referred individual then complete sections 3 and 4.

50 years of age or older 50 years of age or older

Residing in King County, not including Seattle Residing in King County, not including Seattle

Lives independently; not within a nursing home, assisted living facility, adult family home or enrolled in hospice Lives independently; not within a nursing home, assisted living facility, adult family home or enrolled in hospice

Able to walk, with or without assistive devices Able to walk, with or without assistive devices

Experienced a fall in the past 6 months AND called 9-1-1 due to the fall Experienced a fall in the past 6 months AND called 9-1-1 due to the fall

2. Request for Fall Prevention phone consultation

We understand that some applicants may not meet program criteria. To ensure support, a Fall Prevention phone consultation is available to provide information, answer questions and connect individuals with fall prevention resources. Select the box below and complete sections 3 and 4.

I would like to request a fall prevention phone consultation I would like to request a fall prevention phone consultation

3. Referred individual

Enter information for the person being referred to the program.

First and last name

First and last name

Street Address, City, Zip code

Address, City, Zip Code

Phone number with area code

Phone number with area code

Preferred contact name and phone

Preferred contact name and phone

Date of birth

Date of birth

Gender

Gender

History of falls and additional comments

History of falls and additional comments

4. Referring party

Enter information for the person submitting the form.

Referring party's first and last name

First and last name

Referral agency or organization

Agency/organization (or enter N/A if not applicable)

Referral phone number with area code

Phone number with area code

Email address

Email address

Relationship to the referred individual

Relationship to the referred individual