Online Referral

If you encounter any issues completing this form, please contact info@iamboundless.org or 614-436-7837 ext. 8181.

Our office hours are Monday-Friday from 8 a.m. to 4:30 p.m. If you are calling outside of our regular work hours, please leave a message and we will get back with you as soon as possible. 

Referral Information

Were you referred to Boundless by an agency or healthcare provider?*

If you were referred by another agency or healthcare provider, please provide as much contact information as possible.

Referral Source
Referrer's Phone Number:
-
Referrer's E-mail:

Service Information

What services are you requesting? Please provide as much information as possible.*
Please select your appointment preference. *
Which of our locations would you prefer to receive services at (not all services are offered at each location):*
If other, where?
Client Information
Please tell us more about the individual seeking services.
Client's Name:*
Client's Date of Birth:*
Sex:
Client's Address:
Client's Phone:*
-
Client's E-mail:

Guardianship Information
A guardian is defined as someone other than the client that is legally responsible for them. Guardian(s) can be biological or adoptive parent(s) of minor children (under the age of 18) or appointed by the court (if over 18), which can include agencies, parents, or extended family. If applicable, please provide the guardian(s) information AND legal documentation stating the guardianship arrangement from the courts.

Guardian's Name:
Guardian's Phone:
-
Guardian's E-mail:
Relation to Client:
Insurance Information:
What type of insurance do you have?
Primary Insurance:*
What is the primary ID/MMIS insurance number?
Secondary Insurance:*
What is the secondary ID/MMIS insurance number?
If you do not have insurance or would like assistance with this process and/or payment arrangements, please check the box below.

Scheduling Information:

Who is the best person to call about scheduling?*
Contact's Phone:*
-
Contact's E-mail:
What is the best time to call to discuss services?
Can we leave a message? *
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Worthington

445 E. Dublin Granville Road
Worthington, OH 43085

614-844-3800

info@iamboundless.org

Newark

140 W. Church Street
Newark, OH 43055

740-334-4056

info@iamboundless.org

West Carrollton

700 Liberty Lane
West Carrollton, OH 45449

Office

937-247-2400

Secure Document Destruction

937-247-2426

Transportation

937-823-2434

info@iamboundless.org

Medina County

1065 Medina Road
Medina, OH 44256

330-596-1042

info@iamboundless.org