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Community Hub Intake Form

If referring yourself, please select the option “Self-Referral” from the dropdown menu below.

When referring others to the Community Hub, or if you have been referred by a specific organization, please select that organization from the drop-down list. You can type the name of the organization in the box, and a match will populate if it exists in the list.

Options in the dropdown menu are in alphabetical order, except for “Self-Referral” .
If self-referral, enter your name
5. Date of Birth:*
--
Please enter phone number values as 000-000-0000
8. Is it ok to leave a detailed message at this number?*
9. In general, what is the best time of day to reach you?
Select all that apply
If Address is not available, enter 'NA' in Address Line 1.
20. Race/Ethnicities:*
Select all that apply
Drop down menu is sorted alphabetically.
23. Do you (if self-referral) or the individual you are referring have any concerns with the following social needs?*
Select all that apply
24. Do you (if self-referral) or the individual you are referring have any concerns with the following health needs?*

By submitting this referral you are agreeing that you (in the case of a self-referral) or the individual you are referring consent to sharing the personal and healthcare information provided in this form with the HealthierHere Community Hub for potential enrollment into care coordination services. If you or the individual you are referring do not consent to sharing the personal and healthcare information provided in this form, do not submit this form.