NWICA Program Referral Form

  • Resource Connections provides enhanced Information & Assistance

    Resource Connections is a robust information and assistance program to assist Northwest Indiana residents with understanding and accessing information about local programs and services. Resource Connections provides confidential assistance via telephone, online chat, or email by trained specialists and takes a holistic approach to help determine all the needs of the caller and takes the time to explain the referral process which helps equip and prepare the caller; resulting in a greater chance of success when contacting the referral source.

    Anyone can call for information or make a referral so if you are in need or have questions about food, clothing, shelter, Medicare/SHIP, legal services, supports and much more; reach out to us via phone, email or online chat. If you prefer, fill out the electronic online document and one of our highly trained specialists will return your call within two business days with the information you are seeking.

  • If you are an agency making a D-SNP referral, please check this box.
  • MM slash DD slash YYYY
  • Client (person needing assistance) Information

  • MM slash DD slash YYYY
  • Preferred Point of Contact (if not client)

  • Referring Person's Information

  • Disclaimer: The client must agree to any assessment for services. If the client cannot be reached due to incorrect contact information provided referral will not be completed

  • Client Needs

    Please choose one or more types of assistance that you are looking for.
    Answering yes to this question will not disqualify you from any program assistance.
    Answering yes to this question will not disqualify you from any program assistance.
  • Name Date of Birth Sex Actions
  • Signature

  • MM slash DD slash YYYY