Wellness Together Referral Form

Thank you for making the referral to University Settlement. We offer comprehensive social services, nursing services, and health, wellness, and recreational opportunities at people's homes or virtually. Please make sure the person you're referring to us is aware of you doing so. Once we receive the information, we will reach out within 3 business days.

Today's Date

Applicant Information

What is the First Name of the person you are referring?

What is the Last Name of the person you are referring?

Is this person over 60 years old?

What ZIP Code/Neighborhood does the person live in?

What is the best phone number to reach this person?

What language does this person speaks?

Is this person aware of the referral?

Why would you like to make the referral? Tell us a little bit about this person.

Your Information

What is your Name?

What is your phone number?

What is your email address?

What organization/agency are you referring from?

Contact Information