Referrals

Complete the form below if you or someone you know would like to be options counseled regarding comunity resources and eligibility for our In-Home Servcies Program. After we receive the form, we will contact the person listed in the Assessment Contact name. If you would like to call to make a referral, please call 574-284-2644 or 800-552-7928 (within Indiana Only).

County
Name
Street Address
City/State/Zip
Phone
Social Security #	(if known)
DOB
Age
Marital Status
Spouse's First Name
Medicare	Yes
Supplimental Health Insurance:	Yes
Medicaid #
Spenddown Amount
How Spenddown is met
Possible waiver	Yes
Monthly Income
Comments/Health Problems/Disabilities
Assessment Contact Name
Contact Address
Contact Phone Number
Initiated By
Address
Email