Client Referral

Individuals and agencies may use this form to connect with a Community Health Worker.

To visit the Health Care Access Now website go to healthcareaccessnow.org

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* 1. Priority

Urgent

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* 2. Best day to call client

Please specify

Date

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* 3. Agency Information (if self-referral, type N/A in the fields)

Person making referral *

Agency *

Email Address

Direct Phone Number *

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* 4. Client Contact Information

First Name *

Last Name *

Address *

Address 2

City *

State *

ZIP Code *

Email Address

Primary Phone *

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* 5. Client Personal Information

Date of Birth

Race / Ethnicity

Preferred Language

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* 6. Medicaid Insurance Plan Name

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* 7. Medicaid Insurance ID #

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* 8. Do you have any other health insurance plan?

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* 9. Client Needs

Currently homeless

Help with transportation to doctor appointments

Help with utilities

Help paying for medications

Need mental health services

Safety concerns in the home

Need help with food

Urgent Needs

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* 10. If client has a current health condition - describe:

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* 11. Other Needs

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* 12. Number of children in home

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 13. If child has a health condition, please explain. (If none, please use N/A in the field below).

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* 14. What is your (client's) gender?

Female

Male

Non binary