Bridges to Health Pathways Referral Form

Bridges to Health Pathways Referral
All referrals should be sent: b2h@gorgehealthcouncil.org or faxed to 541-397-0004 or via form completed at www.cghealthcouncil.org/bridges-to-health

*Referrals should be sent for households or individuals who have expressed interest in learning more about or wanting to participate in the Bridges to Health Pathways Program. *Clients being referred must live in Hood River or Wasco County
COMMUNITY MEMBER/CLIENT BEING REFERRED
Client or Parent/ Guardian Name
Date of Birth

MonthDayYear
Date
Phone #:
Ok to leave a message?
Ok to text?
Email
example@example.com
Contact Preference

PhoneTextEmail
Client's Physical Address
Client info: Gender identity
Primary spoken language

EnglishSpanishOther:Other
Race/ Ethnic identity:
Does the Client identify with a disability?

YesNo
Is the Client houseless?

YesNo
Is the client a veteran?

YesNo
Household size
Client’s Primary Care Provider Name
Clinic Name
REFERRED BY
Name
Phone #
Email
example@example.com
Today’s Date

MonthDayYear
Date
Agency/ School and your title
BRIDGES TO HEALTH PATHWAYS PROGRAM CRITERIA
To qualify for the program, the answer to questions 1 and 2 below must be ‘YES’
1- Client is struggling to access resources on their own:

YESNO
2- Client understands this program provides support to help access services:

YesNo
3- Services needed

Housing Stability ResourcesPregnancy/ Postpartum ResourcesAssistance with Overcoming Transportation BarriersReferral to get Health InsuranceChildcare ResourcesSubstance Abuse ResourcesPrimary Medical Care/ Dental CareMedication Assistance Programs
3- more services needed:

Utility Resources (medical phone, energy assistance)Food ResourcesClothing & Personal Items AssistanceDocumentation (SS cards, ID, birth certificate)Developmental Referral (EI/ ESD)Referral for Smoking Cessation ProgramsEducation Resources GED, Parenting Ed,Other
Additional Information including other household members with date of birth and age
Phone#:541-705-2705 or email B2H@gorgehealthcouncil.org

Bridges to Health Pathways Community HUB Referral Form Aug 2021
Should be Empty:

Bridges to Health Pathways Referral

COMMUNITY MEMBER/CLIENT BEING REFERRED

REFERRED BY

BRIDGES TO HEALTH PATHWAYS PROGRAM CRITERIA