Family Caregiver 
To care for a family member

By filling out this form you agree that we can submit your referral for approval of services for the Structured Family Care Program. The Area on Aging Company will call you within 3 business days. 
If you have any questions please email us at info@aclindiana.com
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Please tell us who referred you. 
Caregiver First Name  *
Caregiver Last Name  *
Caregiver Email *
Caregiver Phone Number *
What Indiana County do you live in? *
Address
City
Care Recipient First Name *
Care Recipient Last Name  *
Care Recipient Date Of Birth  *
Does this person you care for have Medicaid? ( if they only have Qualified Medicare Benefit) please answer no *
Do you currently live with the person you're caring for  *
Does the person receiving care need help with any of the following activities?  *
Required
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