Please complete this form with the participant or after speaking with them, as specific information on participant needs and functional capacity is needed. If you need assistance with the referral form or have any questions, please contact the IATP ICC staff at (217) 522-7985 or iatp.care@iltech.org.

As a reminder, Illinois Care Connections referrals must address a physical, social, psychological, or emotional need the older adult is experiencing that causes them to be socially isolated, makes them unable to complete tasks they want to complete in their home or community, or leaves them at risk of injury or institutionalization. The requested equipment and services must directly address a specific need for the older adult. If you have any questions on if something is a need or an allowable ICC request, please contact the IATP ICC staff before submitting a referral.

All referrals will be reviewed by ICC staff. During the intake process with the participant, ICC therapy staff will determine what devices appropriately fit the participant's needs. Based on the intake process, specific devices requested may be changed.