Referral Form

All services are provided without regard to race, age, color, religion, sex, gender, sexual orientation, disability, national origin, ancestry, or status as a veteran.
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.
Is this a DSNP referral? This is for insurance providers only. Please skip if this does not apply to you.

Yes
Referral Type *

I am making a referral on behalf of myself. I am making a referral on behalf of another as a power of attorney/guardian, care manager, service provider or health care professional.
If you are making a referral on behalf of another as a power of attorney/guardian, care manager, service provider or health care professional please provide your information below.
Name

First Name Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Phone Extension (If Applicable)
What is your relationship to the individual?
For professionals, please include your employer's name.
Consent: I, the individual listed below, give my permission, verbal or written, for the referral source listed above to release my name, address, phone number, 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.
For the Individual in need of assistance, please provide the following information:
Full Name *

First Name Last Name
Birth Date *

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

Yes No
Race *
Primary Language Spoken *
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 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
Preferred Point of Contact (if not the Individual listed above)

First Name Last Name
Relationship to person being referred.
Contact Person's Phone:
Please enter a valid phone number.
Contact Person's Email:
example@example.com
Is the person listed above the legal representative?

Yes No
If yes, please specify representative.

Guardian Power of Attorney
Identify Individual's Needs (Click all that apply): *

Early Childhood Education (White County only) Energy Assistance (Utility Payment Assistance in Boone, Carroll, Clinton, Hamilton, Hendricks, Tippecanoe and White Counties) General Information Regarding Agency Services and Community Resources Weatherization Program (ONLY in Carroll, Clinton, Tippecanoe and White Counties) Affordable Housing Development Home-Delivered, Congregate Meal Sites, Farmer’s Market Vouchers Medicare Counseling Organization Payee Money Management Services Self-Sufficiency Programs: IDA or BEED Support Group Resources Transportation Section 8 Housing Choice Vouchers (HUD) Medicaid Waiver In-Home Care Services Other (Please Specify Below)
Please Provide a Brief Description of Assistance Needed:
Please verify that you are human *
Should be Empty:

Online Request/Referral Form

If you are making a referral on behalf of another as a power of attorney/guardian, care manager, service provider or health care professional please provide your information below.