Online Referral Form

The information you provide will be kept completely confidential, available only to appropriate ICS staff.

First Name* required

Middle Initial

Last Name

City

Address 1

Address 2

Zip Code

Daytime Phone Number

Evening Phone Number

Cell Phone Number

Email Address* required

Name of Person Making the Referral* required

Relationship to Person Referred

Title (if applicable)

Referring Agency (if applicable)

Address 1

Address 2

City

State

Zip Code

Phone Number

Cell Phone Number

Email Address* required

Website (if applicable)

Do you or the person you are referring have an active Medicaid number?

If Yes, please provide the number

How did you find out about ICS?

Shall we make our initial contact with the person you are referring, or with you?

That’s all we need for now. You may print out this form and fax it to our dedicated Referral Fax line at 718-907-1682, or