Public Health to Isolation Referral wrap around request form B2H ONLY

Quarantine/Isolation Referral for Wrap Around Services

For Bridges to Health ONLY

Bridges to Health Program Fax: 541-397-0004 or B2H@gorgehealthcouncil.org

***As of 12.14.21 the B2H Program has new requirements for referrals***

NEW B2H Requirements

URGENT REFERRAL: Family is in need of any of the following URGENT items to isolate safely (B2H will respond within 1 day):- Food- Medications filled- Emergency HousingNON- URGENT REFERRAL: Family has lost/ will lose wages as a result of the isolation period and will need assistance with (B2H will respond within 1 week):- Rent payment (we are no longer paying mortgages)- Utility Payment

Main contact (Adult/Parent) Name

DOB

Phone number

Address

Primary Language

EnglishSpanish

Today's Date

Date

Estimated length of Quarantine (days)

OTHER HOUSEHOLD MEMBERS:

Family member 1 Name:

Family Member 1 DOB:

Family Member 2 Name:

Family Member 2 DOB:

Family Member 3 Name:

Family Member 3 DOB:

Family Member 4 Name:

Family Member 4 DOB:

Family Member 5 Name

Family Member 5 DOB

Family Member 6 Name

Family Member 6 DOB

Does this client/ family consent to participate in the Wrap Around service support?

YesNo

Does this client/ family authorize our program to release and use their information for coordination of care?

YesNo

What does the family need/Other helpful information? Please indicate here if they are staying at The Shilo Inn.

Referral made by (Name)

Agency

HRCHDNCPHD

Contact information

Public Health to Isolation Referral wrap around service request form B2H 12.13.21