IU Health Geriatrics Referral Form
Fill out this form to refer a patient to a CICOA Community Health Worker.
As of July 1, 2025, IU Health is now supported by a CICOA Community Health Worker (CHW), rather than an Options Counselor, who will meet with clients weekly for up to 90 days. Great candidates for this intervention will have had a recent ER visit or hospitalization, recent fall, chronic illness, or social determinants of health needs (such as housing, food, or transportation.)
CHWs will still pre-screen for all CICOA services, but enrollment processes may look different due to changes at the state level.
CHWs will be notified of referrals submitted through this form and can begin the process immediately. After successfully submitting the form, you will see a green confirmation message and receive a confirmation email.
*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.