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TO: Indiana Developmental Training Center
ATTN: Admissions Department
FAX: 317.815.1645 (Indianapolis) or 765.448.4217 (Lafayette)
To make a formal referral, receive additional information, or get on our mailing list, please fill out the information form below and fax it to 317.815.1645 (Indianapolis) or 765.448.4217 (Lafayette). If there are any questions, please contact an Admissions Representative at 317.815.0505 (Indianapolis) or 765.448.4220 (Lafayette).
Information about the person you are referring
Name of Person You Are Referring: __________________________
Gender: _______________________________________________
Date of Birth: ___________________________________________
Information about you
Your First Name: ____________________________________________
Your Last Name: ____________________________________________
Your Agency: _______________________________________________
Your Phone: ________________________________________________
Your Fax: __________________________________________________
Your E-mail: ________________________________________________
Brief Description of Concerns or Information Requested:
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_____________________________________________________________________
_____________________________________________________________________
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