Click the link below to download the Intake & Referral Form

*If you have problems downloading from the button above, right click with your mouse and select "save as" on this download file: (Intake & Referral Form)

Our Options Counselors are also certified counselors for the State Health Insurance Assistance Program (SHIP).

For further information or to speak with an Options Counselor:

Call 1-800-742-9002 or 812-888-5880

Fax 1-812-888-4568