Referral Information for The Independent Living Center
and Independent Living In-Home Care
The Independent Living Center provides personal attendant services, home modification, adaptive equipment, advocacy, benefits counseling, information/referral and independent living skills training to adults with physical disabilities and chronic health problems in Barton, Barry, Dade, Jasper, Newton, and McDonald counties. Services have various programmatic requirements based on need, age, disability and income that must be met prior to service provision.
Independent Living In-Home Care, provides respite care, authorized nurse visits, home maker chore, personal care and advanced personal care.
To make a referral to one of our programs, please print out and
complete this form.
Consumer Name:______________________________________________________
Date of Referral:_________________________________ Gender:______________
Person Making Referral and Contact Information: _________________________
______________________________________________________________________
Services Needed (describe as fully as possible):____________________________
_______________________________________________________________________
Consumer Address: _____________________________________________________
Consumer Phone Number:_______________________________________________
Consumer Disability:____________________________________________________
Date of Birth:_____________________________ SS #:_________________________
Medicaid Number (if applicable):__________________________________________
Other Insurance (if applicable): ___________________________________________
Alternative Contact:______________________________________________________
Living Arrangement: _____________________________________________________
Other Agencies Providing Services (Describe Services): ______________________
_________________________________________________________________________
Please mail this form to: The Independent Living Center,
1001 E. 32nd Street, Joplin, MO 64804 or fax to: 417-659-8087.
Completing this form does not guarantee services. If you have any questions, please call 417-659-8086 or email us at cdsprogram@ilcenter.info for the Consumer Directed Attendant Program; inhomeservices@ilcenter.info for non-consumer directed In-Home Attendant Services; or ilservices@ilcenter.info for general services.
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