Community Services Referral Form

Welcome to the Independent Age Referral form.  We work in different areas across the country. Please select the area from the list below. If you are unable to see the area where you live then we are not yet working there or do not have capacity at this time.  For General enquiries please contact our helpline on 0800 319 6789.






Please gain the permission of the person you would like to refer before continuing the referral process.
Referrer Contact Details

Participant Details
Participant Address


Alternative Contact Details
Please only complete if this person will be the main contact for making appointments