Send us a referral

Please use the form below to directly submit a referral to the Senior Companion Program. If you would prefer to use e-mail, send your referral to jbeaven@archindy.org.
 

Name of the Person You are Referring:

Referral's Address:

Referral's City:

Referral's State:

Referral's Zip Code:

Referral's Telephone Number:

Referral's Birthday:

Best Person to Contact:

Relationship:

Contact's Telephone Number:

Contact's E-mail:

Name of Person Making Referral:

E-mail of Person Making Referral:

Tell us a little about why you are referring this person:

Do you have pets?


Do you smoke?
Yes
No

What is your hospital of choice?

Do you receive services from CICOA?
Yes
No

Who is your case manager?

Are you a veteran?
Yes
No

Do you receive in home meals?
Yes
No

Do you receive housekeeping services?
Yes
No

Do you have home health aides for personal care?
Yes
No

   

 

 

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