Connections | Self-Referral Form

Community Health Workers are bridging health and social services to community members. Facilitating access to services and improving the delivery of high-quality services in order to overcome health barriers.

Client Information
Name Name * First Last
Date of Birth Date of Birth / MM / DD YYYY
County *

County Barry Eaton Other Other
Race

Race American Indian or Alaska Native Native Hawaiian or other Pacific Islander Asian White/ Caucasian Black or African American Unknown Other Other
Ethnicity

Ethnicity Hispanic/ Latino Not Hispanic/ Latino
Insurance Information

Please provide all insurance information. Insurance will not be billed without prior consent of the client.
Name of Policy Holder
Policy Holder Date of Birth Policy Holder Date of Birth / MM / DD YYYY
Name of Insurance Company *

If unknown or uninsured, type "unknown"
Policy Number *

If unknown or uninsured, type "unknown"
Group Number *

If unknown or uninsured, type "unknown"
Preferred Method of Contact

Please provide at least one method of contact
Best way to reach you: *

Best way to reach you: Phone Call Text Email Letter
Phone/Text Phone/Text - ### - ### ####
Email
Address for Letter Address for Letter
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Reason(s) for Inquiry *

Reason(s) for Inquiry Food Assistance Housing / Utilities Assistance Healthcare Coverage Assistance Substance Use / Harm Reduction Services Medical Care / Mental Health Services Social Services Assistance Transportation Assistance Employment Assistance Other Other

Select ALL options you are needing additional information on.
How did you hear about the program?
Do you or client requesting additional information require accommodations provided by the health department? If yes, please mention them below.
Maximum of 500 characters allowed. Currently Entered: 0 characters.
Please include any additional information you wish to provide.

Connections | Self-Referral Form

Connections | Self-Referral Form

Client Information

Insurance Information

Preferred Method of Contact