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CHW Professional 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. 
I confirm that I am a medical professional of a physician's office, hospital, local health department, or other medical provider. *This question is required.
As a non-professional, please use this link to submit a referral for yourself or for someone you know who needs assistance from a Community Health Worker.

Personal - Family or Friend Referral

 
I confirm the individual being referred is aware and accepts that they will be contacted by a Community Health Worker for services. *This question is required.
Select the county of residence for the individual being referred to a Community Health Worker. *This question is required.
Is the individual being referred a minor less than 18 years of age? *This question is required.
Professional Contact Information: Please provide your contact information in the event the Community Health Worker needs to contact you directly regarding the referral. *This question is required.
Please provide the contact information for the individual being referred to the Community Health Worker  *This question is required.
This question requires a valid date format of MM/DD/YYYY.
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Please provide the minor's parent or legal guardian for contact. *This question is required.
Please identify the referral individual's preferred language for the Community Health Worker services. *This question is required.
What type of health insurance does the person being referred have?
Is the patient being referred for medical needs? *This question is required.
Check all services that the individual needs:
Are there any known safety risks regarding this patient or home? *This question is required.
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