The Fall Prevention Network is a free referral service connecting older adults to multiple resources that can help prevent falls.
- In order to provide a personalized referral, we need to collect the following information:
- Contact information
- History of falls
- Number of medications
- Visit with an eye doctor and primary physician within the year
- Health insurance and approximate income
- We will match you with professionals to help an older adult avoid falls
- We will give you a list of professionals for you to contact
Three ways to request a Free Referral:
Monday – Friday, 9:00 a.m. to 5:00 p.m. (mountain time)
or Fill out the form below
to have a referral specialist contact you.
or Request via a Printed form
Print and fill out a form manually – then mail or fax it back.A. Printable Request Form (print then fill in manually) B. Printable Interactive PDF Version (complete electronically then print)
Many computers already have it, but if your computer doesn’t, you can Download Adobe Reader Here.