External Referral Form
Your First and Last Name
Date of Referral
Your Work Phone Number
Your Work Email
What organization/school district are you from?
Select N/A if not listed
Please type out
organization/school district
(if not listed in dropdown menu):
Who is this referral for?
Adult
Minor
Client Information
First Name
Middle Name
Last Name
Date of Birth
Age
Required for Minor
Parent First Name
Parent Last Name
Child Grade
Student ID
Contact information
Mobile Phone
Email
Other Phone
Preferred Language
Please select...
English
Spanish
Vietnamese
Korean
Cantonese
Mandarin
Other
Unknown
Tagalog
Address Information
Address
City
Zip Code
Client Demographics
Gender
Please select...
Male
Female
Hispanic Ethnicity
Please select...
Yes
No
Race
Please select...
Alaskan Native/Native American (American Indian)
Asian
Black/African American
Multiracial
Pacific Islander
White
Other
Decline To State
Asian Race
Please select...
Vietnamese
Chinese
Korean
Japanese
Laotian
Asian Indian
Other Asian
Filipino
Client Background & Eligibility Information
:
Does the client consent to receiving CHW (Community Health Worker) services?
Please select...
Yes
No
Does client have health insurance?
Please select...
No
Yes
If yes, which Health Insurance Program?
Please select...
Medi-Cal SCFHP
Medi-Cal Kaiser
Medi-Cal Anthem Blue Cross
Other
Private Insurance
Experiencing Homelessness?
Please select...
No
Yes
Pregnancy Status?
Please select...
Currently pregnant
Gave birth in the past 6 months
Not Applicable
Foster Child?
Please select...
No
Yes
Recent Emergency Visits?
Please select...
Visited the ER more than 3 times in the past 12 months
No
Referral Details
Please provide explanation regarding this referral (under 1000 characters):
Account ID
Please contact BibianaV@hkidsf.org for questions.