Referral & Intake

Refer a Client to Source Care Group

Whether you're a case manager, social worker, family member, or self-referring individual, our intake team is ready to help. Complete the form below and we'll be in touch within one business day.

Fast Response

Our intake team reviews every referral within one business day and follows up promptly to begin the eligibility process.

Secure & Confidential

All referral information is handled with strict confidentiality in compliance with HIPAA and Indiana state privacy regulations.

Collaborative Approach

We work closely with case managers, social workers, and families to ensure a smooth transition into services.

Streamlined Intake

Our intake process is designed to minimize paperwork and reduce delays so individuals can begin receiving care as quickly as possible.

Referral Type

Client Information

First Name *

Last Name *

Date of Birth *

Phone Number

Street Address

City

State

ZIP Code

Medicaid ID (if known)

Current Waiver Type

Services Needed

Select all that apply

Referring Party Information

Your Name *

Organization / Agency

Phone *

Email *

Relationship to Client

Additional Details

Urgency Level

Additional Notes