I agree to participate in the Bridges to Health Pathways Community HUB program. I understand that the purpose of this program is to support low-income individuals and their families living in the Gorge to help gain access to healthcare and social services. Agencies participating in B2H work together to provide needed and available services to people who are eligible. Agencies that participate in the B2H Pathways, are referred to as "Community Care Agencies".

Information is shared among the Community Care Agencies to best support connecting you to services. Sharing of information in the B2H HUB allows for information to be collected and helps to ensure that the referrals you receive will be to an organization best suited to assist you.

Participating in this program will provide me with a Home Visitor/ Community Health Worker who will:

• Provide regular home visits (or somewhere where we agree on) for me and my family as needed;
• Work with myself and my family to identify our strengths, concerns and work on a plan for improving our health and well-being;
• Assist myself and/or my family in connecting with community resources to help me meet our needs.

To gain full benefit from the program I will:

• Allow my Community Health Worker to make home or community visits that we agree upon
• Be sure to call and reschedule appointments I cannot keep;
• Participate in the screening questions and assessments that will identify my strengths and needs to help in getting the best services for myself and or family;
• With my Community Health Worker I will develop a plan and work towards meeting my goals;
• Tell my Home Visitor/Community Health Worker if I move or my phone number changes, so she/he/they can still reach me

I am aware and give my consent for basic information regarding progress towards my goals to be entered into a data system, called Activate Care. I am aware that this data, with my name and identifying information removed, will be used by the Bridges to Health Pathways Community HUB program to track outcomes and progress of the program as a whole.

I understand that this is a voluntary program, and that I may withdraw at any time. My withdrawal from the program will not affect my ability to access medical or other services from HUB service providers.