Information and Referral Form -- The Information Center, Inc. The Family Resource Place

Information & Referral Form
Bringing people and services together!

Finding help is as easy as picking up the telephone or completing the form below. Our caring, trained and certified staff will help you sort through the issues and find answers. Remember, our services are free of charge and are totally confidential.

Name:
Phone:
E-mail Address:
Address:
City:
State:
Zip Code:
Age:
Please provide a brief description of your problem:
What is the best way to reach you?
What is the best time of day to reach you?
Number of Seniors Living in the Household? (ages 60 and over)
Number of Children Living in the Household? (ages 0-18)
Number of Adults Living in the Household? (ages 19-59)
Total Family Size?

Information & Referral FormBringing people and services together!

Information & Referral Form
Bringing people and services together!