Submit a Referral

Instructions

All information you provide is secure and confidential. There are multiple ways you can submit a referral:

• Online
  Web: www.idbonline.org/form/referral
• U.S. Mail – fill out the PDF form on paper or online, print and mail it to:
  Iowa Department for the Blind
  524 Fourth Street
  Des Moines, IA 50309-2364
• Fax – fill out the PDF form on paper or online, print and fax it to:
  Fax: 515-281-1263
• E-mail – fill out the PDF form online, save it, and attach it in e-mail to:
  E-mail: information@blind.state.ia.us
  put “REFERRAL” in the e-mail subject line
• Phone in a referral to:
  Local Phone: 515-281-1333; Toll free (in Iowa): 800-362-2587; TTY: 515-281-1355

Referral Form

Personal Information

Additional Information (optional)

Referral Source

If you are completing this form to refer someone other than yourself:

Other Information