Helpline Connection 877‑234‑3641

Make A Referral

You may use the online referral form (below) or submit a completed referral (Referral PDF) by mail, fax or email to:

LifeTime Resources ADRC
13091 Benedict Drive
Dillsboro, IN 47018

Fax (812) 432-3822
Email: contactltr@lifetime-resources.org



Client or Client Representative: I give permission for my clinical provider to give my name, address, phone number, and the client information below to LifeTime Resources so that a representative from LifeTime may contact me or my personal representative about options that are available to me and my family. I understand that LifeTime may provide feedback to my clinical provider based on our contact.

 






Professional Or Clinical Referrals


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.



Identify Client Needs - Check All That Apply (one checkmark is required to submit)