Referral Based in Merrillville, Aspire Home Care is a statewide home care provider! Do you know someone who needs in-home personal care services? Refer them today! If the individual needing assistance lives outside of this area, please lets us know as we will redirect you to the right place. Fill out this form to request a free phone call appointment with a Aspire Care Coordinator. Referral Type *I am making a referral on behalf of myself or as a client representativeI am making a referral as a service provider, healthcare professional or clinicianConsent *I give permission for my clinical provider to give my name, address, phone number, and the client information below to Aspire Home Care so that a phone options counselor from Aspire may contact me or my personal representative about options that are available to me and my family. I understand that Aspire Home Care may provide feedback to my clinical provider based on our contact.Client Information Person needing assistanceClients First Name *Clients Last Name *Birth Date *Phone *Email *Is an interpreter needed? *NoYesAddress *Address 2 *City *State *Zip *Primary disability type or diagnosis *Has the client been in the hospital or a nursing facility in the last 30 days or will be in the next 30 days? *NoYesPreferred Point of Contact (if not client)First Name *Last Name *Contact Person Email *Contact Person Phone *Relationship to client *Professional or Clinical Information Complete this section if you are making this referral as a service provider, healthcare professional, or clinician. If not, please skip to the section "Client Needs."First Name *Last Name *Agency/Clinic Name *Phone *Email **Disclaimer: Client must agree to any assessment for services. If client cannot be reached due to incorrect contact information, provided referral will not be completed.Client Needs Identify client needs*Check all that apply. One check mark is required to submit. *General information about long term services and supportsAssistance with personal care (such as bathing, dressing, toileting, etc.)Caregiver support/respiteEmergency response alert buttonsHome modifications/repairs/accessibilityHousing (independent, assisted living, nursing facilities)Meals (home-delivered, meals sites, meal prep)Medical supplies or equipment (ex. adult diapers)Medicare or Medicaid counselingPublic benefits application assistance (ex. SNAP)Support groups/friendly visiting/senior activitiesTransportationOtherSend Message
