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Ottawa Pathways to Better Health
Program Referral Form
Referral Source Information
Referral is for:
An Adult
An adult with an appointed legal guardian
Is the client aware:
Yes
No
Name of Person Completing the Form
Referring Agency
Type of Referral Agency
211 Referral Agency
Ambulance Service
Area Agency on Aging
Community Health Worker
Community Mental Health
County Human Service Office
Emergency Department
Health Plan
Home Health Agency
Primary Care Practice
Self-Referred
Specialty Care Practice
Phone Number
Fax Number
Email
Best way to reach?
Phone
Fax
Email
Client Information
Date of Birth
(Important, if known!)
First Name
Last Name
Address
City
State
Zip
County
Allegan
Muskegon
Ottawa
Phone Number
Email
Best way to reach?
Phone
Fax
Email
Does this client need an interpreter:
Yes
No
Gender
Male
Female
Due Date (if pregnant)
Ethnicity
Hispanic or Latino
Non-Hispanic or Latino
Primary Spoken Language
English
Arabic
Bosnian
Burmese
Chinese
Farsi
French
Hindi
Hmong
Nepali
Spanish
Somali
Swahili
Vietnamese
Other
Race (check all that apply)
White or European American
Black or African American
Asian or Asian American
American Indian or Alaska Native
Native Hawaiian & Other Pacific Islander
Other
Insurance Type (check all that apply)
Medicaid or Healthy Michigan Plan
Medicare
Commercial
None
Other
Name of Health Insurance Plan
Primary Doctor Name
Name of Practice
Primary Doctor Phone Number
# of ED visits in the past 12 months
# of hospital admissions in the past 12 months
Chronic Health Conditions (check all that apply)
Addiction/Substance Abuse
Anxiety
Arthritis
Asthma
COPD
Depression
Diabetes
High Blood Pressure
Hyperlipidemia
Stroke
Tobacco
Unsure
Other
Reason(s) for Referral
Adult Main Reason for Referral
Access to Community Resources
Access to Behavioral Health Services (includes mental health/substance abuse)
Access to Medical Provider
Chronic Conditions Management
Inappropriate ED use
Medication Concerns
Needs Medicaid Coverage
Pregnancy or Postpartum Support
Recent Hospitalization/Readmission Risk
Other Reasons for Adult Referral
Abuse/Neglect
Access to Behavioral Health Services (includes mental health/substance abuse)
Access to Community Resources
Access to Medical Provider
Chronic Conditions Management
Disability
Environmental Risk (mold, lead, pests, etc.)
Inappropriate ED use
Medication Concerns
Needs Medicaid Coverage
Pregnancy or Postpartum Support
Recent Hospitalization/Readmission Risk
Other
Any Additional Information
Please provide any additional information regarding the reason for this referral that may be helpful in determining eligibility into our programs. Please explain any concerns you may have checked off.