Older Adult Program Referral 
Please use the form below to submit a referral to one of our social connectivity programs at the United Way of Lackawanna, Wayne & Pike Counties. Upon completion, the individual will be contacted within 7 days. If unsure or just looking for more information about any of our programs for those 60 & over, please select "General Information" when choosing a program.
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Your Name:
Your Organization (if applicable):
Referral's Name (individual you are referring):
Referral's Birth Year: 
Referral's Address (so that we may send a postcard reminder):
Referral's Phone Number:
Do you give the United Way consent to contact this individual?
Clear selection
Please select program(s):
Date of Referral:
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/
DD
/
YYYY
 Reason for Referral & Notes
Case Manager Name (if applicable):
Case Manager Phone (if applicable):
Submit
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