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CHW Referral

Community Health Referral

Our Mission: To connect residents of Carroll, Gallatin, Owen, and Pendleton counties with
resources to support their health and well-being through trusted Community Health Workers.

Are you submitting this request on your behalf or for someone else? *This question is required.

As the referring requestor, you confirm that the individual being referred accepts the referral and is aware that a CHW will be contacting them directly. *This question is required.

Select your county of residence. *This question is required.

Please select the county of residence for the individual you are referring for the CHW services. *This question is required.

Please provide your name and phone number to be contacted by the CHW in your community *This question is required.

First Name
Last Name

Phone Number

Please provide the name and contact info for the referral *This question is required.

First Name
Last Name

Phone Number

Referring individuals contact informaiton *This question is required.

First Name
Last Name

Phone Number
Title

What type of health insurance do you have? *This question is required.

What type of health insurance does the person being referred have?

Please identify your preferred language for the CHW services. *This question is required.

Please identify the referral candidates' preferred language for the CHW services. *This question is required.

Please provide any notes and/or additional information you feel is appropriate.