Care Intake/Referral Form

Care Intake/Referral

Greater Health Now (GHN) serves Asotin, Benton, Columbia, Franklin, Garfield, Kittitas, Walla Walla, Whitman, Yakima Counties, and the Yakama Nation. We are an independent nonprofit organization committed to building vibrant and healthy communities. We partner with local organizations to help coordinate care that addresses real needs, and helps more people thrive.

If you are experiencing an emergency, please call 911 immediately.

*Very important information or section required

Client Information

Client First (Given) Name*:

Client Last (Family) Name*:

Preferred Name:

Client Date of Birth*:

Gender*:

Preferred Language*:

Other language (if "Other" selected above)

Email:

Best Contact Number:

Extension:

Contact Number Type:

Is it ok to leave a detailed message at this number?

In general, what is the best time of day to reach you?

Address:

Greater Health Now (GHN) serves Asotin, Benton, Columbia, Franklin, Garfield, Kittitas, Walla Walla, Whitman, Yakima Counties, and the Yakama Nation.

Street Line 1
Street Line 2
City
County
State
Zip Code

Race/Ethnicities:

Referral Source

Type of entity making referral*:
If referring yourself, please select the option "Self" from the drop-down menu. If you have been referred by a specific organization or are referring someone else to the Community Hub, please select the type of organization from the drop down menu, and include name of organization and person making referral, along with phone and email.

Referral Source Organization:

Referring person (first and last name):

Referral Source Phone Number:

Referral Source Email:

Insurance

Please enter details about your primary insurance plan.

Plan Type

Plan Name

Member ID Number

Start Coverage

End Coverage

Social and Health Barriers

Does the client have any concerns with the following Social Barriers? Select all that apply.

Housing
Food Access
Utilities
Clothing
Childcare
Employment or Employee Assistance
Eldercare
Education
Communication (phone/Internet/computer)
Transportation
Safety: Violence or abuse
Safety: Home or environment
Safety: Neighborhood or Community
Guidance with SSI/ SSDI
Legal Aid
Youth Support

Does the client have any concerns with the following Health Barriers? Select all that apply.

Health Insurance
Health Care: Covid - Acute
Health Care: Covid - Long Term
Health Care: Primary care
Health Care: Specialty care
Health Care: Medications
Health Care: Dental
Health Care: Vision
Health Care: Navigating the healthcare system
Health Care: End of life support
Health Care: Birthing/doula/prenatal services
Behavioral Health: Substance Use Treatment
Behavioral Health: Medications
Behavioral Health: Inpatient treatment
Behavioral Health: Outpatient treatment
Behavioral Health: Therapy
Behavioral Health: Developmental Disability

Other referral needs:

Consent

By submitting this referral form, you confirm that the prospective client has provided informed consent to share the information included here with the HUB for the purpose of determining eligibility and potential enrollment in care coordination services.

Submitting a referral does not guarantee eligibility or placement. All referrals are reviewed based on program criteria and the availability of resources. Referrals with incomplete or limited information may be delayed or deemed ineligible.

All information will be handled in accordance with applicable privacy laws and regulations, including the Health Insurance Portability and Accountability Act (HIPAA), where applicable.

Consent *
I have read and understand the information above (Clear)

Only click the Enroll button once - it may take a while to process! Clicking it a second time will result in a duplicate enrollment.