Central Ohio Pathways HUB
New Client Referral Form

Client Information:

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* 1. Client Name, First & Last:

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* 2. Client Date of Birth

Date / Time

Date

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* 3. Client Preferred Gender Identity:

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* 4. Client Race/Ethnicity:

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* 5. Client Street Address (If homeless please indicate):

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* 6. Client City, State, Zip Code (If homeless, provide zip code of area residing):

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* 7. Client Best Contact (Phone Number/Email):

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* 8. Referring Agency Name:

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* 9. Referring Agency Contact Name:

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* 10. Referring Agency Best Contact (Phone Number/Email):

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* 11. Are you a Columbus Metropolitan Housing Authority resident?

Yes

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* 12. Please check all areas of concern:

Alcohol/Substance Abuse

Asthma

Childcare

Clothing

COVID-19

Depression or Other Mental Heath Concern

Developmental Delay of Child in Family

Domestic Violence

Education Assistance-Adult

Child/Youth Education Assistance

Family History of Child Abuse/Neglect or Involvement with CPS

Family History of Heart Disease/ Diabetes

Financial Assistance

Food

Housing

Insurance

Job/Employment

Legal

LGTBQ-specific needs

Low Income

Medication Assistance

Obesity

Physically inactive

Poor Diet

Smoker/Tobacco User

Stress

Transportation

Child under age of 18 living in the home

Pregnant

Cancer Diagnosis OR Caregiver of someone with Diagnosis

Other :

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* 13. If pregnant please indicate estimated delivery date:

Date / Time

Date

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* 14. Insurance Status:

Medicaid

Medicare

Uninsured

Private

Unknown

Medicaid Managed Care Plan Name

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* 15. *Please provide any additional information that may be helpful to the Pathways HUB:

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* 16. By checking this box, I consent the referring agency stated in question 7 to share the above information with the Central Ohio Pathways HUB for the purposes of enrollment into the Pathways Program.

consent

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* 17. Client Consent

Print name:

Date: