Arizona Links Screening Tool for Maricopa County Residents
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When you have completed the form, click the ‘Submit’ button at the bottom of the page, an Information Specialist from the Area Agency on Aging, Region One (AAA) will contact you to discuss the options that are available to you.

Please submit a separate Screening Tool for each person seeking services.

If you need assistance to complete this screening tool or would like additional information, please contact (in Maricopa County) the AAA Senior HELP LINE at 602-264-4357 or toll free at 1-888-264-2258

  1. What is your primary reason for filling out this Screening Tool?

       
      
  2. Have you contacted the AAA Region One, Inc. before?
      
      
  3. I am seeking information/care for:

      
  4. Please select a Zip Code / Location:

      
  5. The date of birth of the person identified above is (month-day-year):
      
    Month: 
    Day:  Year (four-digit format 1944): 
       
  6. Assistance with the following tasks is needed: (check all that apply)
      
     
        
  7. Assistance with the following household chores is needed: (check all that apply)
      
     
        
  8. The current care situation is such that: (check all that apply)
      
       
  9. Most pressing needs are: (check all that apply)
      
       
  10. Monthly (GROSS) income level is:

    1. For an individual, No more than:
    2. For a couple, No more than:
      
      
  11. Current health insurance coverage is: (check all that apply)
      
        
        
  12. Medical conditions include: (check all that apply)
      
     
        
  13. I was referred by:
Your contact information:
Your first name:
Your area code and phone number:
Alternate phone number:
Email Address:

           (You will be prompted to complete any required fields that are blank)

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