CHLC Program Referral Form

Program Referral Form

CT Healthy Living Collective
Participant/Client Information

This form is HIPAA Compliant and all information is strictly confidential.
Name:*

First NameLast Name
Gender:*

FemaleMaleTransgender FemaleTransgender MaleGender Variant/Non ConformingPrefer Not to AnswerType my own answer
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Contact Phone:*
Please enter a valid phone number.
Birthdate:*

MonthDayYear
Date
Email:
example@example.com
What is your primary language?
Health Goals/Concerns
Select all that apply:*

Manage Chronic PainManage Diabetes (or Pre Diabetes)Decrease Fall Risk/Improve BalanceLearn About Healthy EatingConnect with LGBT CommunityHealthy AgingDecrease Social IsolationManage ArthritisManage Cardiovascular Disease/HypertensionDecrease Anxiety or Depression
Referrer Information
Referral Date:*

MonthDayYear
Date
Referrer Name:*

First NameLast Name
Referrer Email: *
example@example.com
Referrer Organization:*
Referrer Phone:*
Please enter a valid phone number.
Authorization to Disclose Information
By signing below you hereby authorize voluntarily disclosure of the information in this form for the purpose of being referred to a CT Healthy Living Collective or other chronic disease education/self-management program or service. Information shared may include name, address, phone number, date of birth, primary language and health goals/concerns related to the referral. This personal information may be shared between and among the CT Healthy Living Collective and the program to which you are being referred. You understand the additional information related to the referral, including whether you participated in the programs to which you were referred and the outcome of your participation. You also understand that you may revoke this authorization at any time by contacting the referrer listed above. If you revoke this authorization your personal information will no longer be shared and will be protected by federal and state law.
Signature:*

Clear
Date:*

MonthDayYear
Date
Instructions
- Please have the person being referred sign this form to disclose information to the CT Healthy Living Collective.
- A copy will be email for your records.
- Plesae contact the CT Healthy Living Collective at cthealthyliving@ctcommunitycare.org with any questions.
Should be Empty:

Program Referral Form

Participant/Client Information

Health Goals/Concerns

Referrer Information

Authorization to Disclose Information

Instructions