IC4 Referral

Home
About Us
Fact Sheets
Training
Resources
Donate
Español
Events
Heart to Heart Conference
Walking for Dreams
Contact Us

Home
About Us
Fact Sheets
Training
Resources
Donate
Español
Events
Heart to Heart Conference
Walking for Dreams
Contact Us

INDIANA COMPLEX CARE COORDINATION COLLABORATIVE

The Indiana Complex Care Coordination Collaborative (IC4) is housed at Indiana University School of Medicine with a goal to coach and embed nurse care coordinators into primary care practices across the state of Indiana, aimed to provide care coordination for a population of 3,000 children with medical complexity and adults with intellectual disabilities primarily through the use of shared plans of care. This form was created for exclusive use by IC4 partners.
If you have reached this form in error, please return to the INF2F Contact Us page.

* Indicates required field

Referred By *

First

Last

Medical Practice *

Email *

Phone Number *

Contact Name *

First

Last

Contact Ethnicity *

Hispanic or Latino Non-Hispanic or Latino

Relationship to Child *

Preferred Language *

INF2F has Bilingual (Spanish / English) Resource Specialists available to support families in their preferred language.
For families in need of other language support, please note specifics using the "Referral Summary" field at the bottom of this form.

Contact Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Contact Demographic Information *

Asian Black or African American Multiple Races Native American / American Indian or Alaskan Native Native Hawaiian or Pacific Islander Some other race Unknown White

County of Residence *

Child's Name *

First

Last

Child's DOB *

Child Demographic Information *

Asian Black or African American Multiple Races Native American / American Indian or Alaskan Native Native Hawaiian or Pacific Islander Some other race Unknown White

For reporting purposes only, Check all that apply.

Child Ethnicity *

Hispanic or Latino Non-Hispanic or Non-Latino

For reporting purposes only.