Refer Someone to Independence Now

Would you like to access our services or speak with one of our staff more about the services we offer and how we might work together to accomplish your Independent Living goals? Are you working with or supporting a person with a disability who you have spoken to about IN and they are interested in exploring our services?

Please complete this form and refer yourself or someone else to Independence Now. We will follow up by phone or email to see how we can work together toward independence!

* All fields are required

Person being referred:

If you are referring yourself, please check the box below. If you are referring someone else, please complete the remainder of the form before submitting it.

Person making the referral: