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
Insurance Information

Please provide all insurance information. Insurance will not be billed without prior consent of the client.
Name of Policy Holder
Name of Insurance Company *

If unknown or uninsured, type "unknown"
Employer Name
Policy 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 Utilities Assistance Social Service Referral Medical Referral Health Insurance Health Education Mental Health Referral 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.

Connections | Self-Referral Form

Connections | Self-Referral Form

Client Information

Insurance Information

Preferred Method of Contact