Refer or Request Information

Who are you referring/requesting information for?

In case we need to follow-up with you.

First name

e.g John

Last name

e.g. Doe

Phone

Best number

Email

Organization

How long will this take?

The form your about to complete will only take 3 to 5 minutes for most people. The type of information we will be requesting includes:

Personal details
(e.g. name, email, DOB)
Mailing address
A question or two to help learn about what services you are interested in (it’s okay if you don’t know)

Voice/TDD
508-583-2166 or 800-649-5568
Fax
508-583-2165
PCA Dept. Fax
508-583-2184
Contact Staff Members

Independence Associates, Inc.
100 Laurel Street, Suite 122
East Bridgewater, MA 02333

Hours
Monday – Friday: 9 a.m. – 5 p.m.
Closed weekends and holidays.

Full Name

Email

Consumer Satisfaction Survey

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