Requests can only be made by an authorized agency with a valid Agency Code
* = required
Referring Agency Point of Contact
Please complete the information below for the participant:
(The participant is the individual for whom the device is being requested. Please involve the participant in the collection of this data.)
The responses to the questions will be scored as follows:
|Some of the Time
The score for each individual question is tallied together to give you a possible range of scores from 3 to 9.
Assistive Technology and Information Technology Options
The Illinois Care Connections Program offers access to assistive technology devices (AT) and durable medical equipment
(DME) to assist older adults age 60+ in living more independently and safely. It is also intended to help them to be more connected to family, friends, access health providers and participate in recreational
activities through technology.
General Screening Questionnaire
This program is funded by the Illinois Department on Aging
The Illinois Department on Aging does not discriminate in admission to programs or treatment of employment in programs or activities in compliance with
appropriate State and Federal Statutes. If you feel you have been discriminated against call the Senior Helpline at 1-800-252-8966, 1888-206·1327 (TTY).