CORE Referrals

CORE (Counseling, Outreach and Referral for the Elderly) is a mental health, substance use disorder counseling and care coordination program for people 55 and older.

In-home assessments for people 60 and older are conducted with funding support from Elder Services of Cape Cod and the Islands.

Please complete this form to refer someone to either of these services.

Referral for CORE Services

"*" indicates required fields

MM slash DD slash YYYY
Name of person completing referral*
Client's Name*
Client's Gender*
MM slash DD slash YYYY
OK to leave message?*
OK to leave message?
Emergency Contact*
Client's Physical Address*
Client's Mailing Address (if different than physical address)
I give permission to the Island Counseling Center (ICC) to notify (the referring source) that the Island Counseling Center has contacted me regarding the CORE or CORE Assessment Program.*