NWICA Program Referral Form

  • Resource Connections provides enhanced Information & Assistance

    Resource Connections is a robust information and assistance program to help Northwest Indiana residents understand and access local programs and services. Resource Connections' trained specialists provide confidential assistance via telephone or email. Our team takes a holistic approach to identify everything the caller needs and explains how to access each referral. Knowing what to expect increases the caller's confidence when reaching out to new resources.

    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, in-home supports or any other human or social service need, reach out to us via phone or email. If you prefer, fill out the electronic online document and one of our highly trained specialists will return your call in the order your referral was received.

  • 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, 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