NICIL Online Referral Form

This form is a simple, easy, online referral form. You provide the information, and one of the NICIL team members will contact you for a follow-up. 100% confidentiality!

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    * Date of birth is used for providing you with age appropriate resources. This is only for NICIL use.
  • NICIL supports all people with disabilities, this knowledge helps us to prepare the right information for resources based on the needs an individual has.
    Please check all that apply to your needs:
  • A NICIL team member will be in contact with you within three (3) business days*. If there is a specific day of the week or time that is more convenient, please note that here. * {NICIL is open Monday-Thursday 8:00 am to 4:30 pm and closed on all major holidays. However, please note that we will make after-hour calls to you during a time and day that is convenient to you. }
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