Referral Form

1 of 5
Are you a Professional (doctor, social worker, etc.) applying on behalf of a consumer?
Consumer Information
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Gender Information
Current Gender (Choose ALL that apply)
Sex assigned at birth on original birth certificate (Check one)
Sexual orientation or sexual identity (Check one)
Consumer Address
Referral Source

NON-DISCRIMINATION STATEMENT AND POLICY

COSA does not and shall not discriminate based on race, color, religion (creed), gender, gender expression, age, national origin (ancestry), marital status, sexual orientation, or military status, in any of its activities or operations. These activities include, but are not limited to, hiring and firing of staff, selection of volunteers and vendors, and provision of services. We are committed to providing an inclusive and welcoming environment for all members of our staff, consumers, volunteers, subcontractors and vendors.

©1996-2025 All Rights Reserved.

location

Delaware County Office of Services for the Aging
1510 Chester Pike, Suite 250
Eddystone, Pa  19022

Toll Free: 1-800-416-4504

www.delcosa.org

Monday through Friday 
8:30AM to 4:30pm

phone

610-490-1300

fax

610-490-1500

Email

COSA@co.delaware.pa.us