Online Request/Referral Form

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 or long-term services and supports (in-home care, assisted living, nursing facility placement, etc.), assessment 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.

Area Five serves the following counties in Central Indiana: Cass, Fulton, Howard, Miami, Tipton, and Wabash. If the individual needing assistance lives outside of this area, please visit in.gov/fssa/inconnectalliance to locate the appropriate Aging & Disability Resource Center (ADRC).

***If you are seeking information on behalf of someone else, please notify the individual that you are making this referral and Area Five will contact them by phone. Individuals have the right to refuse any and all services, including Area Five's initial phone assessment. In the event that Area Five has attempted to make contact with the individual without success, it will be the responsibility of that person to contact Area Five directly through the Aging & Disability Resource Center at 574-737-2100. Area Five staff will contact the preferred point of contact if one is listed, but due to the right of refusal we cannot initiate an assessment through anyone but the client unless the client has a cognitive deficit.

****Area Five Agency does not have any emergency or immediate based services through our funding sources. We have to complete assessments to determine eligibility and work with providers to support care needs.****

Area Five 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.

Online Request/Referral Form

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I am making a referral...








What is your name?

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Check all that apply (at least one).






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. Area Five Agency 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.