Request Help Form

The COAAA Online Request Form allows seniors, caregivers, and professionals in Central Ohio to request aging, caregiving, and long-term care assistance directly from the Area Agency on Aging.

Older adult with a headset on while using a computer

Make a Request

COAAA serves eight counties: Delaware, Fairfield, Fayette, Franklin, Licking, Madison, Pickaway, and Union. If you are outside this area please visit Ohio Association of Area Agencies on Aging or call 1-866-243-5678.

Note: Required fields are denoted with a red asterisk (*).

Who is Submitting the Information?

Please enter a valid name.
Please enter a valid phone number.
Please enter a valid email address.
Please select an option.
Please select a preferred method of contact.
Please select a reason for contact.
Please select one.
Please enter a valid message.

Who Needs Services?

Please enter a valid name.
Please enter a valid address.
Please enter a valid city.
Please select a county.
Please enter a valid state.
Please enter a valid zip code.
Please enter a valid phone number.
Please enter a valid email address.
Please enter a valid age.