• 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

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

  • Consent

  • Individual Information

    Person needing assistance


  • All services are provided without regard to race, age, color, religion, sex, gender, sexual orientation, disability, national origin, ancestry, or status as a veteran.

  • Should be Empty: