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Wellness Works!

Thank your for your interest in Wellness Works: Wellness Care Coordination Program. This is an awesome opportunity for people to grow and get healthy through care coordination and wrap around services.

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* 1. Who is making this referral?

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* 2. Do you have permission to refer this person to the Wellness Care Coordination Program OR are you referring yourself?

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* 3. What is your association to the person being referred to the program?

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* 4. Who is being referred to the Wellness Care Coordination Team (skip section if no phone, email)?

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* 5. Do you have regular access the Internet?

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* 6. How do you access the Internet? (Choose all that apply)

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* 7. Gender

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* 8. What is the person's race/ethnicity?

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* 9. What is the person's primary language?

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* 10. What is the person's age range?

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* 11. What is the person's date of birth?

Date

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* 12. What is the person's sexual orientation?

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* 13. Please identify the person's living situation?

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* 14. Which systems is the person currently involved with (List all that apply)?

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* 15. Does the person have a history of using substances?

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* 16. Which substances is the person CURRENTLY using, please check all that apply (If not using, mark NA)?

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* 17. Does the person have a history of overdose?

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* 18. Does the person have a history of intravenous drug use (IV/needles)?

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* 19. Does the person have any of the following health conditions (please mark all that apply)?

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* 20. Does the person have any of the following behavioral/mental health conditions (please mark all that apply)?

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* 22. Has this person ever had COVID-19?

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* 23. Has this person experienced any type of trauma?

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* 24. Is this person active military/veteran?

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