Referral Form

Online Request/Referral Form
For a cost free call from an Area IV’s Information and Referral Specialist

If you are inquiring on behalf of someone else, please notify the individual that you are making this referral and that Area IV Agency will contact them by phone. We can be reached by telephone at 765-447-7683 ext. 401 or info@areaivagency.org.

Referral Type
Choose *

I am making a referral on behalf of myself or as a personal representative of someone else. I am making a referral as a service provider or agency, health care professional, or clinician.
If you are making a referral as a service provider, health care professional, or clinician, please list your contact information below
Name

First Name Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Phone Extension (If Applicable)
Consent
I give permission for the referral source to give my name, address, phone number, and the individual’s information below to Area IV so a phone options counselor from Area IV Agency may contact me or my personal representative about options and resources that may be available to me and my family. I understand Area IV Agency may provide feedback to the referral source based on our contact. *

Individual/personal representative consents to this referral.
Individual Information

Person needing assistance
Full Name *

First Name Last Name
Birth Date *

Month Day Year
Social Security Number (Not Required)
Hispanic / Latino *

Yes No
Race *
Gender Identity *

Female Male Other Identity
Veteran Status *

Active Military Veteran Not a Veteran Unknown
Phone Number *
E-mail
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Is the person needing assistance currently in the hospital or rehabilitation facility? *

Yes No
If yes, please indicate the projected discharge date
Has the person needing assistance recently been discharged from a hospital or nursing facility? *

Yes No
If yes, please provide the discharge date
Has the person needing assistance recently visited the emergency room? *

Yes No
If yes, please list the date of the emergency room visit
Is the person needing assistance aware of the referral being made to Area IV Agency? *

Yes No
Is the person needing assistance willing to accept help from Area IV Agency? *

Yes No
If you are completing this referral on behalf of the person needing assistance, what is your relationship to the individual?
Please Provide a Brief Description of Assistance Needed:
Preferred Point of Contact (if not the person in need of service)

First Name Last Name
Relationship to person being referred.
Are you a legal representative?

Yes No
If yes, please specify representative.

Guardian Power of Attorney
Contact Person's Phone:
Please enter a valid phone number.
Contact Person's Email:
example@example.com
Identify Individual's Needs (Click all that apply): *

Early Childhood Education (White County) Energy Assistance (Utility Payment Assistance in Boone, Carroll, Clinton, Hamilton, Hendricks, Tippecanoe and White Counties) General Information Regarding Agency Services and Community Resources Home Repair Services (Weatherization Program in Carroll, Clinton, Tippecanoe and White Counties) Affordable Housing Development In-Home Care Services Meals (Home-Delivered, Congregate Meal Sites, Farmer’s Market Vouchers) Medical Supplies or Equipment (ex. Adult Incontinency Products) Medicare Counseling Money Management Services Self-Sufficiency Programs (IDA, BEED, Life Skills Coaching) Support Group Resources Transportation Rental Housing Vouchers (Section 8) Other (Please Specify Below)
If you selected Other, please specify below:
All services are provided without regard to race, age, color, religion, sex, gender, sexual orientation, disability, national origin, ancestry, or status as a veteran.
Please verify that you are human *
Should be Empty:

Online Request/Referral Form

If you are making a referral as a service provider, health care professional, or clinician, please list your contact information below