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

Phone Number

Fax Number

Best way to reach? Phone Fax Email

Client Information

Date of Birth (Important, if known!)

First Name

Last Name

Address

City

State

Zip

County

Phone Number

Best way to reach? Phone Fax Email

Does this client need an interpreter: Yes No

Gender Male Female

Due Date (if pregnant)

Ethnicity

Primary Spoken Language

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 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.

Ottawa County Administration
12220 Fillmore Street
West Olive, MI 49460

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