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Wellness Work Care Coordination Referral Form

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.
1.Who is making this referral?(Required.)
2.Do you have permission to refer this person to the Wellness Care Coordination Program OR are you referring yourself?(Required.)
3.What is your association to the person being referred to the program?(Required.)
4.Who is being referred to the Wellness Care Coordination Team (skip section if no phone, email)?(Required.)
5.What is the person's date of birth?
Date
6.What is the person's Social Security Number?
7.Gender(Required.)
8.Do you have regular access the Internet?
9.How do you access the Internet? (Choose all that apply)
10.What is the person's race/ethnicity?(Required.)
11.What is the person's primary language?(Required.)
12.What is the person's age range?(Required.)
13.What is the person's sexual orientation?(Required.)
14.Please identify the person's living situation?(Required.)
15.Which systems is the person currently involved with (List all that apply)?(Required.)
16.Does the person have a history of using substances?(Required.)
17.Which substances is the person CURRENTLY using, please check all that apply (If not using, mark NA)?(Required.)
18.Does the person have a history of overdose?(Required.)
19.Does the person have a history of intravenous drug use (IV/needles)?(Required.)
20.Does the person have any of the following health conditions (please mark all that apply)?(Required.)
21.Does the person have any of the following behavioral/mental health conditions (please mark all that apply)?(Required.)
22.Does this person have observable or documented cognitive impairment? If so, at what level?
23.Has this person ever had COVID-19?(Required.)
24.Has this person experienced any type of trauma?(Required.)
25.Is this person active military/veteran?(Required.)
Current Progress,
0 of 25 answered