Online Request/ Referral Form

Get started with community resources and long-term care options

Fill out this form to request a free phone call appointment with an Options Counselor in the Aging & Disability Resource Center.

Options counseling is a free service that helps older adults, people with disabilities, and family caregivers think through the various options for long-term services and supports. Options counseling may include a review of long-term services and supports (in-home care, assisted living, nursing facility placement, etc.), assessments for home- and community-based services (Medicaid waivers, CHOICE, home-delivered meals, etc.), or community resource referrals (housing, legal, food pantries, etc.). Referrals will be responded to in the order received.

CICOA serves the following counties in Central Indiana: Boone, Hamilton, Hancock, Hendricks, Johnson, Marion, Morgan, and Shelby. 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 notify the individual that you are making this referral and that CICOA will contact them by phone. Individuals have the right to refuse any and all services, including CICOA’s initial phone assessment. In the event that CICOA has attempted to make contact with the individual without success, it will be the responsibility of that person to contact CICOA directly through the Aging & Disability Resource Center at 317-803-6131.

CICOA can only accept this referral form, not healthcare providers' own forms, in order to obtain the information needed to assist our community members. Alternatively, you may download and print a fax form here.

If you do not see the form displayed below, please try to refresh the page (Ctrl+F5 on PC, Shift+Cmd+R on Mac), or try another browser. We are troubleshooting this error that some people have encountered.

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. CICOA Aging & In-Home Solutions will 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.