Iowa Association of Area Agencies on Aging (i4a)
Service Intake Form

Overall Agency Information

Agency Information
Service/Agency Name:
Contact Person/title:
Physical Address (including zip code):
Address:
City:
County:
Service Area:
State:
Zip:
Mailing Address (if different from physical address):
Address:
City:
State:
Zip:
Local Phone Number:
Toll Free Number:
TTY Number (if applicable):
Email address:
Agency Type:
For Profit   Non-Profit   Public
Please list any organizations you are accredited/licensed by:
Services
Below is a list of the types of services we include in our database. Please mark all of the services you provide from the list below and complete the corresponding forms (found on this web-site) for each service. For more information about our terminology, refer to the Service Definitions page or the Types of Services PDF.

Adult Day Care Case Management Educational Programs Elder Rights Services Emergency Response Systems Employment Services Financial Assistance Financial Guidance Health Clinics Health Conditions Health Support Products Home Based Services Hospice Care Hospitals Housing Options Housing Services Income Supplements Information and Assistance Insurance Assistance Legal Assistance Mental Health Services Nursing Home Nutrition Services Organizations Recreation and Socialization Respite Care Support Groups Transportation Volunteer Services Wellness Programs
Name/phone/e-mail of person completing this form
Name:
Phone:
Email:
Questions? Call Toll Free at 1-866-468-7887 to talk with our Information and Referral Specialist.