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MAKE A REFERRAL

Options counseling is a no-cost service that helps older adults, people with disabilities and family caregivers think through the various options for long-term services and supports. Referrals will be responded to in the order they are received. 

AIHS serves the following counties in northeast Indiana: Adams, Allen, DeKalb, Huntington, LaGrange, Noble, Steuben, Wells and Whitley. If the individual needing assistance lives outside of this area, please visit: in.gov/fssa/inconnectalliance to locate the appropriate Aging & Disability Resource Center. 

If you are seeking information on behalf of someone else, please have them available during the phone appointment to provide consent for screening, or notify the individual that you are making this referral and that AIHS will contact them by phone. Individuals have the right to refuse any and all services, including AIHS's initial phone assessment. If we cannot successfully contact the individual, it will be the responsibility of that person to call the Aging & Disability Resource Center at 260-469-3036.

Referral Type
Consent

I give permission for my clinical provider to give my name, address, phone number and the client information below to Aging & In-Home Services of Northeast Indiana so that a phone options counselor from AIHS may contact me or my personal representative about options that are available to me and my family. I understand that AIHS may provide feedback to my clinical provider based on our contact.

Client Information
Preferred Point of Contact
Client Needs
Identify client needs - check all that apply. One check mark is required to submit.

The referral form requests information that is privileged and confidential, including patient information protected by Federal and State privacy laws. We use security measures on our website to protect against the loss, misuse and alteration of data used by our system. Aging & In-Home Services of Northeast Indiana wil not share, sell, rent or distribute personal information with anyone without your permission or unless ordered by a court of law. Information submitted to us is available only to employees managing this information for purposes of contacting you and assessing eligibility for services.

We will be in contact with you soon!

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