Older Adult Services Request Form

If you need information on health, housing, financial or other issues, submit your requests to Older Adult Services. We'll get you in touch with community and hospital resources. Just tell us what you want to know by filling out and submitting this referral form on-line. You may also print this form, fill it out and mail it to:

Older Adult Services
William Beaumont Hospital
3535 W. Thirteen Mile Road, Suite 108
Royal Oak, MI 48073

We will respond to your request within four business days. If you have any questions, call Older Adult Services toll-free in Michigan at 1-800-328-2241, or at 248-551-0777.

Step 1: How can we contact you?
 
Contact via:
First Name
Last Name
Address 1
Address 2
City
State / Province
Zip / Postal Code
   
Home Phone
 -
Only numbers please.No dashes.
Work Phone
 -
Only numbers please.No dashes.
Fax Number
 -
Only numbers please.No dashes.
E-mail Address

Step 2: Tell us what you need

Other:

If you are asking for someone else, in which city and state does that person live?


What is the age of the person needing information?


Step 3: Submit the form.
  Beaumont Secure & Private

Your personal information is secure and private.