Referral Information

Your Name Phone Email Relationship to Individual

Individual’s Information

Name Date of Birth Guardian (if applicable) Guardian Phone Home Address Emergency Contact Name Emergency Phone

Communication Preferences

Phone call: YES Text Messages: YES Email: YES

Estimated Support Needs

Estimated IHCS hours needed per week (a rough guess is fine)

Reason for Referral

What support does your loved one need? Has your loved one received waiver services in the past? (Optional)

Additional Notes

Date